Police: Station Closures
	 — 
	Question

Lord Hunt of Kings Heath: To ask Her Majesty's Government how many police stations have been closed since May 2010.

Lord Henley: My Lords, this information is not collected centrally. Decisions about resources are, rightly, matters for chief constables to take locally with their police authorities. What is important is how visible and available the police are. We want to see police officers on the streets, preventing and cutting crime, rather than behind their desks. Modern policing reaches people through many means, not just through police stations.

Lord Hunt of Kings Heath: My Lords, I am most grateful to the noble Lord for that illuminating Answer. Could it be that the Government do not collect this information centrally because the information is too embarrassing to them? Can the Minister confirm that the recent Sunday Times survey that showed 350 public counters due for closure in the next few months is accurate? Can he also confirm that his ministerial colleague in the Home Office, Lynne Featherstone, has been running a campaign in her constituency against police cuts and the closure of public counters? Does he agree that this is somewhat hypocritical, and does it not show that she knows that these cuts are going to have an impact on the police's ability to fight crime?

Lord Henley: My Lords, I am aware of the research in the Sunday Times to which the noble Lord refers. I am not sure it was conducted on the most scientific basis and therefore we will not take much notice of it. I am also aware of what my honourable friend Ms Featherstone had to say about issues in her own constituency. I understand her views were purely about her own constituency, and she is a very good constituency MP. I can assure the House that, like all government Ministers, she is fully committed to what the Government and the Home Office are doing to make the necessary savings-savings forced on us by the profligate manner in which the party opposite behaved when they were last in government.

Baroness Doocey: My Lords, I declare an interest as a member of the Metropolitan Police Authority. Does the Minister agree that the economic situation and budget cuts may force the new police commissioners to choose between maintaining police numbers and selling police properties?

Lord Henley: My Lords, I thank my noble friend for that question, and I am aware that she is a member of the Metropolitan Police Authority. The question is about police contact, and the important thing to remember is that police contact is not just about stations; as I made clear in my original Answer, it is about police stations and all other means by which we can achieve that police contact. Police stations are not necessarily always the best means of doing that.

Lord Harris of Haringey: My Lords, I, too, declare an interest as a member of the Metropolitan Police Authority. Given that contact is the key issue, how does the Home Office view the decisions by the Mayor of London and his deputy for policing to cut by nearly a half the number of sergeants responsible for safer neighbourhoods and liaising closely with local communities? Is that not a significant reduction in contact with the community?

Lord Henley: The noble Lord is a member of that police authority and will no doubt put those questions to the mayor in due course. The important point is that those decisions are made by the appropriate authority. It is not for us to micromanage these things; it is for us to make the appropriate resources available to the police. We accept that the cuts that we are having to make, which were forced on us by the previous Government, are difficult. However, they are challenging but manageable, and all police authorities will manage to achieve them.

Baroness Chalker of Wallasey: My Lords, will my noble friend the Minister encourage chief constables to use those early-retired persons who are prepared to volunteer their services both to man desks in police stations and to carry out other non-police but essential back-up tasks? This is working extremely well in a number of areas of the Metropolitan force, and I believe that it should be widely extended across the country.

Lord Henley: My noble friend makes a very good point indeed and I will certainly take it on board. It is quite right that we should make use of the expertise that we have to make sure that policemen who are still available for front-line duties can do them and are not wasted behind the doors of the police station doing bureaucratic jobs.

Baroness Smith of Basildon: My Lords, perhaps I can help the Minister, who said that he does not know how many police stations have closed. In my county of Essex, seven police stations have closed, but, worse than that, we now have no more 24-hour police stations, and most police stations are open only between noon and 6 pm. Given that the Chief Inspector of Constabulary said that a 12 per cent cut in police budgets was the most that could be saved, how can the Government justify a 20 per cent cut in Essex? What impact will this have, and why did they not listen to the chief inspector?

Lord Henley: My Lords, that is obviously a matter for the authorities in Essex. We accept that things will be difficult, as I have made clear in all the supplementary answers that I have offered to the House. The noble Baroness will be aware of the most recent report from HMIC, Adapting to Austerity, which was published in July this year and which sets out a summary of forces' workforce plans for the spending review period. The numbers working in front-line roles is expected to fall by just 2 per cent on average, but it must be for each force to decide how to do that itself.

Lord Brooke of Sutton Mandeville: Since the Official Opposition are leading with their chin, does my noble friend recall that under the doctrine of collective responsibility Labour Ministers were seen on the picket lines and at the protests against the closure of hospitals in their constituencies?

Lord Henley: My Lords, it is not unusual for the Opposition to lead with their chin, so perhaps I ought to remind them of what one of their own former police spokesmen said only too recently. Vernon Coaker, the former shadow Police Minister, said:
	"Ideally, you want the station to remain in the town but if that's not possible and they don't have the money then we have to look at alternatives ... A lot of areas do operate without a station but they all have a presence".

Lord Taylor of Blackburn: My Lords, what would the Minister's reaction be to the recommendation, if it was made, that the police station at Penrith close?

Lord Henley: My Lords, I am not aware of such a suggestion, but, if it was made, obviously I would want to discuss it with the chief constable of the authority I happen to live in. However, it would be for him and not for me or for any other Home Office Minister to decide what was appropriate for Cumbria policing and policing in Penrith.

Baroness Farrington of Ribbleton: My Lords, would the Minister care to comment on the Government's priorities for the police service in this country, given that they are introducing, at great public expense, an untried and unpiloted new system that replaces police authorities instead of using that money in the way the overwhelming majority of the public want it to be used: on the police service in their locality, including police stations?

Lord Henley: I will not rehearse the debates that we had at some considerable length on the police Bill when it recently went through this House. This House and another place, Parliament as a whole, decided in favour of police commissioners, which we feel is the right way forward and is what we will do. It will create much greater local accountability. If the noble Baroness looks at what we have at the moment in the form of police authorities and what we will have in the future with police and crime commissioners, she will, in due course, recognise that that will be a great improvement.

EU: Economy
	 — 
	Question

Lord Dykes: To ask Her Majesty's Government what conclusions they have reached from the discussions of European Union Finance Ministers in Luxembourg on 4 October concerning the case for member states to work together to solve their current economic problems.

Lord Sassoon: My Lords, the Government support the euro area's commitment to ensure financial stability of the euro area. A comprehensive and sustainable solution is urgently needed and is in the UK's interest. This can be achieved only by the euro area working closely together. The Government also recognise the urgent need to boost growth across the EU and are pushing completion of the single market, promotion of trade, reduction in regulation and greater innovation.

Lord Dykes: My Lords, I thank the Minister and the whole Government for having shown steady and firm solidarity with our eurozone partner countries and for their strenuous efforts to solve current financial and economic problems. Does he agree that such a firm stance must be maintained to stop deep market panic despite the monumental shock of the Greek referendum decision?

Lord Sassoon: I am grateful to my noble friend for recognising the constructive role which the UK Government have played in pushing forward the many strands of important discussion in the EU at the moment. I indeed agree that the agreement signed last week has to be delivered by all member states, including Greece. We will be working hard to play our part to that end.

Lord Liddle: Does the Minister agree that, in this very grave moment of crisis for Europe and for Greece, we should be urging the Greeks to recognise that, for all the inevitability of hard and painful times that lie ahead for them, it is the eurozone that is forgiving half their debts, rescuing their banks and providing the financial support to keep their economy afloat? Should the British Government not hold out a hand of friendship to Greece, for whose democracy we have a proud historical record of support, and not indulge in arrogant lecturing by a Government whose economic policies are leading to depression in this country?

Lord Sassoon: My Lords, we hold out a hand of friendship to all our EU partners and to many other countries, but it is for Greece to make its own decisions. I am not going to lecture the Greeks, but it is clear that all parties to the deal last week have to deliver on their commitments.

Lord Higgins: My Lords, is it not high time that the usual channels got together and arranged for a debate in this House on the crisis in the eurozone, since we have had no opportunity other than on Statements and Questions to pursue the matter so far? In particular, should we not have some views expressed on the contingency plans which need to be made should a country leave the eurozone?

Lord Sassoon: My Lords, without wishing to encourage a huge rush of additional speakers, we already have a decent number of very interested and expert noble Lords down for a debate on Europe tomorrow. Indeed, this House is taking the matter very seriously.

Lord Reid of Cardowan: My Lords, is it not obvious to all but the most blinkered zealot that, whether the Greeks default or not, in the medium to long term the only prospect of survival for the eurozone-even that is not guaranteed-is with such a centralisation of political and fiscal ancillary powers that we would effectively have created qualitatively two different European structures? Will the Government enlighten us on what contingency planning they are making as to when the day will inevitably come when that decision or decisions have to be made?

Lord Sassoon: My Lords, I do not accept the very simplistic idea that we are headed for a two-speed Europe. There is already a variable geometry in Europe in other areas apart from the euro, such as justice and home affairs, where there are different arrangements for certain member states. The critical lesson out of all this is that the UK must stick to its own fiscal deficit reduction policies because it is those which are giving us the benefit of 10-year interest rates today at 2.2 per cent, whereas countries such as Italy, which had interest rates very similar to ours before the financial crisis, have interest rates not at 2.2 per cent but at 6.2 per cent. So we must stick to keeping our own house in order.

Lord Pearson of Rannoch: My Lords, further to the question put by the Minister's noble friend Lord Higgins, have the Government given any thought to the cost of returning first Greece and in due course the other crippled economies of the eurozone to their national currencies and, if necessary, supporting that transition with some variation of the Marshall plan? Have they thought about that concept, compared with continuing to throw unknown trillions at a project which cannot be saved?

Lord Sassoon: My Lords, the first thing to understand is that the UK is not part of the stability mechanism that the eurozone is putting in place, and we will not contribute to specific bailouts. On the other hand, the eurozone takes about 40 per cent of our exports and it continues to be the principal interest of the UK Government to make sure that the eurozone and the whole of the EU prosper and grow, to the benefit of our own economy.

Lord Grocott: Could the Minister spell out the difference between a variable geometry Europe and a two-speed Europe?

Lord Sassoon: My Lords, I think that I have already done so. The two-speed Europe that people seek to paint is one between the eurozone and the rest, but thanks to the work of the Prime Minister at the 23 October Council, the very important principle was accepted that those matters which relate to all EU members and the whole of the EU, such as the single market, will of course continue to be the province of the EU 27. That is the critical acceptance which has been made by the Council and the Commission at the prompting of the Prime Minister.

NHS: Private Healthcare
	 — 
	Question

Lord Collins of Highbury: To ask Her Majesty's Government whether general practitioner practices are permitted to advertise their own private healthcare services using the NHS logo.

Earl Howe: My Lords, the Department of Health does not permit organisations, including general practitioner practices, to use the NHS logo to promote their non-NHS services, including private healthcare services.

Lord Collins of Highbury: I thank the noble Earl for his response, but of course most of us in the Chamber have read in the newspapers recently about the case of a GP practice writing to its patients. I believe that what happened there goes straight to the heart of general practice; that is, the relationship between the doctor and the patient. It is a relationship that I fear the Government show no sign of understanding. Will he give an assurance that the proposed form of commissioning in the health Bill will not result in the nightmare possibility of the doctor changing from the person who decides the best medical treatment for the patient to the person who decides what can be afforded?

Earl Howe: My Lords, I can give that broad assurance, but the noble Lord will know that it is already within the GMC code that doctors have to consider the totality of the resources available to them and take account of the needs of all their patients. With that qualification, of course our reforms are designed to ensure that the highest quality care is delivered to every patient according to his or her needs.

Lord Walton of Detchant: My Lords, is the noble Earl aware that in the 1980s, when I was president of the General Medical Council, it was unethical for doctors to advertise and those who did could be disciplined? However, I and a number of other members of the council were summoned before the Office of Fair Trading and were accused of restraint of trade. After a lengthy hearing, it was agreed that GPs should be allowed to advertise, but that consultants should not in order to preserve the gatekeeper function of a GP for access to special services. Has the situation changed?

Earl Howe: My Lords, the issue of advertisements is slightly different from the issue surrounding logos, in particular the NHS logo. What I can tell the noble Lord is that where independent providers have their own logo and wish to use it, they can within the specifications outlined in the NHS guidelines. In cases where organisations are providing both NHS and private services, and those could include a general practitioner, then the information relating to the private services must not carry the NHS brand or logo type, and information relating to the private services must be kept separate from the NHS ones.

Baroness Gardner of Parkes: I have been a national health dentist. Surely the national health logo could be in the premises without necessarily being on the advertisement. It is important that practitioners should be clear on these matters. Patients want to know what services are available, whether they are national health or private and what the choices are, and it would be a deficiency on the part of a national health practitioner not to at least have information available. How can you differentiate so that it is not claimed that the NHS logo has been involved when you are basically a national health practice?

Earl Howe: My Lords, other than for GPs, dentists and pharmacists, where use of the logo is voluntary-although it is very widely used-providers of NHS services are required to display the NHS logo as a sign of their commitment to the NHS patients that they treat. That is fine as far as it goes. However, where private services are also being delivered from the same premises, there are clear rules laid down that the NHS logo must be nowhere near any information about those services and that patients have to be absolutely clear what service they are receiving, whether it is NHS or private.

Lord Harris of Haringey: On the basis of that answer, does the noble Earl accept that it is inappropriate for an NHS general practitioner, during an NHS consultation with a patient, to offer their own private, non-evidence based-services instead of an NHS service -in other words, to offer their own private services in the context of an NHS consultation? I speak from personal experience.

Earl Howe: My Lords, except in limited circumstances, which must be set out in their contract, primary medical service contractors-GPs, in other words-cannot directly or indirectly seek or accept from any of their patients a payment or other remuneration for any treatment. The prohibition not only relates to treatment provided under the primary medical services contract but extends to any treatment that may be provided to the patient.

Baroness Jolly: My Lords, we all agree that the NHS logo must be one of the most trusted brands in the UK. It is currently outside diagnostic and treatment centres which are privately run, so can the noble Earl tell the House whether the Government will issue guidance to any qualified private providers about the use of the logo?

Earl Howe: The rules as regards any qualified private providers will remain exactly as they are now. There must be absolute clarity as to when services are being provided by the NHS and when they are not.

Baroness Thornton: My Lords, perhaps I may press the Minister, following on from the question of the noble Baroness, Lady Jolly. I looked at the NHS brand guidelines website and it is most specific about the colours, size, margins, borders and even communication principles. It is silent, however, about who cannot use the NHS logo. It has a list of organisations which can use it but is silent about who cannot. Given that we may be heading towards a world with a multiplicity of providers, will the Minister undertake to look at the NHS brand guidelines with a view to making it clear under what circumstances the brand may or may not be used?

Earl Howe: I will, of course, look at that point. However, the NHS logo is considered to be the cornerstone of the NHS brand identity. The letters NHS and the logo type are trademarks managed by the branding team at the Department of Health on behalf of the Secretary of State for Health, who technically holds the trademark. They are extremely well recognised and trusted, and use of them is very carefully controlled indeed.

Baroness Finlay of Llandaff: Are the Government satisfied that the general practitioners in the focus of this Question were not subject to double payment-first, paid under the terms of their GMS contract for general medical services to patients on their list, and, secondly, then receiving private payments for giving the service that had already been paid for under the GMS contract?

Earl Howe: My Lords, I have already indicated that there must be a clear separation between NHS services provided by a general practitioner and its private services-or indeed services for which it is entitled to charge that fall outside its contract. The rule is that patients should be left in no doubt about which service they receive.

Energy: Carbon Capture and Storage
	 — 
	Question

Lord Ezra: To ask Her Majesty's Government what are the prospects for carbon capture and storage after the withdrawal of the Longannet project.

Lord Marland: My Lords, the prospects for carbon capture and storage in the UK are good. We have six other applicants in the European new entrants' reserve 300 competition. Through FEED, we have developed substantial practical guidance on the delivery of CCS projects. We will launch a streamlined selection process for future CCS projects as soon as possible and expand on our plans in the next eight weeks. I can confirm that the £1 billion remains available for this.

Lord Ezra: My Lords, while it is regrettable that the Longannet project has been withdrawn, it is satisfactory to note that these other projects are coming forward and, in particular, that the Government will speed up the selection process. Would the Minister agree that a successful demonstration of carbon capture and storage on a commercial scale could not only reduce carbon emissions but also lead to the creation of many new jobs and substantial overseas earnings?

Lord Marland: My Lords, it is difficult to disagree with any single word that the noble Lord, Lord Ezra, said. He is obviously a leading expert in the field. It is gratifying to hear him make a statement like this and be so supportive of the Government's plans.

Lord Lawson of Blaby: My Lords, is it not clear that the withdrawal of the Longannet proposal demonstrates what most people who have studied this know, that carbon capture and storage is a lovely idea but is both technologically improbable and economically prohibitive? Is it not about time, when there is great financial and public spending stringency, that the Government stopped throwing money at this lost cause?

Lord Marland: My noble friend Lord Lawson makes several good points. The reality is that that is why, having been the negotiating Minister for the project, I decided to call a stop to it. I felt that the financing for this particular project was going off the dial. We have been given an envelope with which to invest, one that is more than generous for the prospect. It is part of the coalition agreement and there is support from all sides of the House that we press on with this groundbreaking technology. Britain is famous for groundbreaking technology and we should-and will-continue to invest in that.

Lord Winston: My Lords, I declare an interest as a member of the Engineering and Physical Sciences Research Council. Does the Minister agree that it is likely that there will be a considerable use of fossil fuels, particularly coal, in many parts of the world and there is clearly a commercial advantage in Britain being first? Would he remind the House how much money we spend on research in this area through the research councils? Does he feel that that is sufficient money in view of the importance of this area?

Lord Marland: I can only talk about what the Government have spent in FEED, which is their investigative, exploratory work on this. To date, we have spent more than £60 million-quite a significant figure. As I said earlier, we have committed £1 billion to the project. We will learn even more as we go into the next project and I hope that we will be successful.

Lord Teverson: My Lords, I very much welcome the renewed commitment of the Government and my noble friend to carbon capture and storage in future. Will the Government look at fossil fuels other than coal? How do they see co-operation with other nations, for instance China, in developing this technology to our mutual benefit?

Lord Marland: I am grateful to the noble Lord, Lord Teverson, for his very good points. The reality is that if we all had our time again we would start on gas, which is going to be fundamental to the future of our energy supply. I am at one with the noble Lord, Lord Lawson, on this, for a change. I very much hope that in the next competition we will have a lot of applicants for a gas project and that we can become world leaders in its carbon capture and storage.

Lord Broers: My Lords, does the Minister agree with me that of course all these low-carbon energy approaches are risky and expensive? This is further evidence that for CCS this is particularly the case. We have had our two large projects stopped; it could be incredibly expensive and feasibility is far from demonstrated. Does not that teach us that we had better get on with nuclear power in a more aggressive way and expand our nuclear capability?

Lord Marland: I am delighted to say that on 31 October EDF put its 30,000-page document in for planning for the first new nuclear power station to be launched for 27 years. I can only totally agree with the noble Lord.

Baroness Worthington: My Lords, I am very grateful for the Minister's comments about gas. It is certainly true that if we could be back in time we should have had a much broader approach to the competition. How does the Minister intend to communicate to the Treasury the lessons learnt from this negotiation? This is an important technology and cannot be done on the cheap. We must provide sufficient funds to get this technology out and proven, so that we can become a world leader in it.

Lord Marland: I am very grateful for the support of the noble Baroness, Lady Worthington. I can confirm that the Treasury has agreed to £1 billion of support for this, in addition, one hopes, to European money for which we are applying. In my own view, that is a very significant figure in these current times to support this project.

Baroness Smith of Basildon: My Lords, the Minister indicated in his Answer that European funding may be available for CCS. Given the collapse of Longannet, will the UK still be able to meet the timescale for that funding, and can that funding be used for capital support for carbon capture and storage projects in this country?

Lord Marland: I can confirm to the noble Baroness that that is the case. I would not say that Longannet has collapsed; we have merely said that we are not going to proceed with it. But I can confirm that that is the case.

Health and Social Care Bill
	 — 
	Petition

Lord Kennedy of Southwark: My Lords, I beg leave to present a petition from Lewisham SOS NHS.
	The petition prays that the House will recognise the clear present and future danger of the Health and Social Care Bill 2011 to the health and well-being of people and that the Bill be withdrawn from further consideration forthwith.
	Petition presented.

Procedure of the House Committee
	 — 
	Membership Motion

Moved By The Chairman of Committees
	That Lord True be appointed an alternate member of the Select Committee in place of Lord Hunt of Wirral, resigned.
	Motion agreed.

Rehabilitation of Offenders (Amendment) Bill [HL]

Bill Main Page

Report

Report received.

Health and Social Care Bill

Main Bill page

Committee (2nd Day)

Relevant document:19th Report from the Delegated Powers Committee, 18th Report from the Constitution Committee.
	Clause 1 : Secretary of State's duty to promote comprehensive health service
	Debate on Amendment 3 resumed.

Baroness D'Souza: My Lords, I would like to remind the Committee that if either Amendment 3 or Amendment 4 is agreed to, I cannot call Amendment 5 by reason of pre-emption. I call the noble Baroness, Lady Williams of Crosby.

Baroness Williams of Crosby: I apologise for the slight delay in rising to my feet-my understanding was that the Minister was proposing to start the debate by making a statement. I apologise for delaying the House. Let me say right away that I do not resile in any way from the amendment which the noble Baronesses, Lady Jay and Lady Thornton, the noble Lord, Lord Patel, and I have put down. We believe that it is important to have an absolutely solid basis by which the whole of the House and the public can understand exactly the accountabilities and responsibilities of the Secretary of State. It is therefore of great importance that this House, in this crucial Committee sitting, is able to reach a clear understanding of what those responsibilities and accountabilities are.
	I very much hope that that will be possible as there are still legal questions about the particular meaning of both the amendment put forward by the noble and learned Lord, Lord Mackay of Clashfern, and the amendment put forward in the names of the noble Baroness, Lady Jay, myself and others. There are still difficulties and differences of opinion between legal voices about exactly what the forethought of those amendments is and just how clearly they lay out the responsibilities and accountability of the Secretary of State. Some Members of this House will recognise that one difficulty is that the Secretary of State is extremely anxious to avoid any further micromanagement of the health services because he believes that it would reduce professional discretion. I think that many of us sympathise with that argument.
	The difficulty is that many of us also believe that the Secretary of State should have clear accountability for the very large sums involved in financing the NHS at present. We also have regard to the fact that there are certain crucial responsibilities revolving around things such as national emergencies for which we believe the public would expect the Secretary of State to be the person responsible. So on constitutional grounds, and on grounds of financial accountability and clear responsibility in certain areas of national concern, we are anxious to see that the Secretary of State retains those responsibilities. However, the possibility of drafting legislation which comprises both the issue of having no micromanagement and the issue of the crucial ultimate responsibilities of the Secretary of State has proved somewhat elusive. In that situation, I hope very much that the Government will consider pressing ahead with trying to draft acceptable legislation for Report stage, when I hope there can be broad agreement about what the responsibilities are. I cannot answer for my noble friend the Minister, of course, but I hope that he will give consideration to that request.
	Perhaps I may quickly add three other considerations. The first, which I have mentioned already, is the area of legal ambiguity. I think that all Members of this House will have heard clashes of opinion about the precise meaning of the amendment before us. I regret that, and I hope the legal profession will forgive me for saying that when there is more than one lawyer in a room there is very often more than one opinion. That is exactly the situation in which we find ourselves. Secondly, many of us feel-I would certainly speak for myself and my party, and this point was raised by the noble Baroness, Lady Jay-that it is absolutely critical to look at Clauses 4 and 10 together with Clause 1, rather than trying to take them separately. They are intimately interrelated. Many of us recognise that to make a change in Clause 1 without taking on board the implications of Clauses 4 and 10 would leave us in a world of deep twilight uncertainty.
	The third issue is perhaps a bigger one; perhaps it constitutes a vision that I profoundly hold. I think we all recognise that the NHS is deeply cherished in this country. It is something to which people cling, as they find themselves facing financial hardship, as one of the few certainties and areas of trust that they can rely on. However, we also know without any doubt of the essential need for change in the NHS-my noble friend the Minister and others have made this absolutely clear-if we are to be able to finance an aging population, and not least, although we often neglect this, the very welcome survival of far more people with chronic sicknesses than used to be the case even 20 years ago, all of which lays heavy responsibilities on the health service. Because of that, I for one feel strongly that the greatest prize that this House could give to the future of health services in this country would be to reach a broad political consensus on the issue, so that the NHS and other health services, as they go forward, find that they are based on a solid rock of acceptance and consensus that will carry us through many of the ups and downs that we are bound to face in the next few years.
	Therefore, I ask the Minister of State whether he will consider asking those of us who have put down amendments-I am one of them-to withdraw them in light of the need for further discussion. That would allow us to bring forward, I hope, a very broadly agreed proposal at Report stage in this House, when we have also considered the issues around the autonomy clause.
	Finally, I add one more thing, for which I hope I will be forgiven. I know that those who have been in the House for a long time are fully aware of this, but it may be helpful for those relatively new Peers who are not fully aware of it. If an issue is brought up in Committee and then voted on and voted down, it cannot come back again on Report or at any other stage of the proceedings on the Bill. That would be disastrous. It would mean that if any vote were carried, we could not then go back to trying to get broader and stronger agreement on Report. It would simply mean that the whole issue disappeared. This is far too important an issue to be allowed to disappear. Therefore, I plead with those who I fully understand passionately support my amendment or that of the noble and learned Lord, Lord Mackay of Clashfern, to allow their passions to be put to one side, temporarily at least, while we contemplate the absolute necessity of debating this more fully, trying to draw a consensus from it and accepting that we can go back to these matters on Report, when a vote would be appropriate, right and timely.

Lord Mackay of Clashfern: My Lords, in response to the obvious concern over the Secretary of State's responsibilities, as narrated in the Bill, I attempted to find, from a completely impartial point of view, a solution that would commend itself to everyone. In due course, I came up with an amendment, which your Lordships have seen. My first action was to send a copy of it to the noble Lord, Lord Owen, and others, including the noble Baroness, Lady Thornton. I hope that demonstrated that there was nothing partisan or anything of that sort about it. In trying to put the amendment together, I looked very closely at what the Constitution Committee had said. I think the noble Baroness, Lady Jay, and I demonstrated last time that we had considered these matters in some detail.
	I also considered all that had been said about concerns on this matter in the Second Reading speeches, of which there were quite a few. I have endeavoured to meet these concerns in the amendment. As I say, I hoped that the House would find it acceptable but a number of questions have been raised and, as the noble Baroness said, lawyers are apt to disagree on these matters. On the other hand, lawyers are usually reasonably able to reach agreement when they set their minds to it. Therefore, I have no intention of moving my amendment today so there can be no question of its acceptance or otherwise today. An amendment to it has been proposed by my noble friend Lord Greaves. He told me that his idea was to find out what the meaning of "ultimate" was. Maybe I should briefly deal with that now. "Ultimare" is the Latin verb from which it comes, which means to come to the end-not always a comfortable position. The definition in the Oxford English Dictionary is:
	"Lying beyond all others; forming the final aim or object".
	That is the sort of idea that I had-that it is the final responsibility of the Secretary of State; in other words, in ordinary language, "The buck stops here". That was my object in using that phraseology.
	During my researches in the Oxford English Dictionary I noticed that Dr Johnson said in 1758 that to be idle is the ultimate purpose of the busy. As I say, I have no intention of moving my amendment today. I hope that we can reach agreement on this matter in informal discussions outside the Chamber. A large number of important practical issues remain to be considered in subsequent Committee days. This sort of question, which is primarily rather theoretical but very important from the point of view of people's attitude to the National Health Service, should be determined. However, it would be more conveniently determined in discussions between ourselves outside the Chamber. Certainly, I would be willing to participate in those discussions if the amendments before us today are not proceeded with.

Earl Howe: My Lords, before we move further forward with our debate, I hope that noble Lords will find it helpful if I make a very brief intervention. I am aware that a number of noble Lords wish to speak and I have no wish to prevent that. The Committee must, of course, proceed as it sees fit. However, I felt it might be useful to those intending to speak if I indicated now rather than later what the Government's preferred course is in relation to this group of amendments. Some noble Lords will be aware that the Government regard the amendment tabled in the name of my noble and learned friend Lord Mackay and the noble Lord, Lord Kakkar, as having particular merit in the context of this debate. Notwithstanding that, and having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report to reflect further on these matters in a spirit of co-operation. I shall, of course, say more when I wind up the debate but it may assist the Committee to know that that is the position that I shall be taking.

Baroness Thornton: In the spirit of co-operation across the House it might be useful if I outline the position of these Benches, too. During the past few days I have said to anybody who would listen to me that this is the position in which I thought we probably ought to end up. Those who have been sitting with me on the Long Table can bear testament to that. The reason I added my name to the amendment of the noble Baroness, Lady Williams, is because I feel strongly that that is the right way forward. I am very pleased to hear that the noble Baroness has not resiled from her position on that. I have talked to several lawyers and consider that the amendment in the name of the noble and learned Lord, Lord Mackay, may address political issues but does not fully address the legal issues concerning the responsibility of the Secretary of State.
	I have what I can assure noble Lords is a sparkling 10-minute speech, but I do not intend to make it now. However, I may save it for a later occasion. I think this is a good solution if other noble Lords agree with it. I look for an assurance from the Minister about how the discussions on this matter should proceed. We have a record on this Bill of cross-House discussions involving all the people with an interest and expertise in matters relating to it. In that spirit, I wish these amendments to be withdrawn so that not only our lawyers but our medical experts, and, indeed, the Constitution Committee, can be persuaded to have another go at this issue. Towards Christmas we may find a solution that suits us all. If not, I may instead have to make my 12-minute sparkling speech on Report. I hope that the House will feel that this is a good way forward.

Lord Laming: My Lords, it is clear that around the whole House it is felt that the constitutional position of the Secretary of State is of immense importance. The House must give careful thought to that issue in order that we get it right, because the National Health Service is important to every citizen, as we heard earlier during our consideration of a Question. What the health service stands for, how it carries out its responsibilities and where responsibility and accountability rests are of great importance.
	The House is indebted to all those Members who have put their names to the amendments. They are thoughtful amendments that represent the best interests and work of this House. It is a great credit to those who have put their names to the amendments that they are happy to consider withdrawing them today, because it is important that the House should not take precipitous action, that we accept the thoughtful response from the Minister and that we give plenty of time and opportunity to try to resolve this. There is actually a shared commitment around the House, and I therefore have every confidence that the House will reach agreement. I very much hope that noble Lords who have tabled these amendments will accept this opportunity to meet with the noble Earl and resolve this matter before the next stage of the Bill.

Baroness Jolly: My Lords, I am hugely grateful for the position where we now find ourselves. I am in total agreement with the previous speakers that we need to move this issue on, take back Clauses 1 and 4, use the same sort of language, and bring the matter back on Report. I should like to put on record how I am totally in awe of the work of my noble friend Lady Williams in this regard. We have also been hugely helped by the clear thinking of the noble Lord, Lord Marks of Henley.
	While I am thanking people, I should also like to say how much I welcomed the approach of the noble and learned Lord, Lord Mackay of Clashfern. We should recognise the amount of work he put into his amendment. It was useful to take a fresh approach to what was becoming a thorny problem and bring to the House new language to look at, because, for reasons that we have already rehearsed, we were not too happy with the proposals. One of the matters that I should like the Minister to take back with him-here I borrow some language from the noble Lord, Lord Hennessy, which I think he used at Second Reading-is consideration of whether we can maintain the DNA of the Bill when producing the new work that will come before us on Report.
	From these Benches, I repeat that we need a reworked clause with completely unambiguous language that will reflect the duties of the Secretary of State for the 21st century and the new NHS that we are trying to forge.

Baroness Andrews: My Lords, I think I can add the support of these Benches to the extraordinary way in which this matter has been resolved. It is a great tribute to my noble friend Lady Thornton, who has led so many of the debates across this House, during which many aspirations have been drawn out, problems identified and voices collected. The Minister responded clearly to what the noble Baroness, Lady Williams, expressed so well: the peculiar trust and confidence that is held in the National Health Service in this country and how careful we must be in our processes to honour that expectation and trust, so that clarity on the legal responsibilities and the future of the NHS is absolutely secure.

Lord Mawhinney: My Lords, I would not presume to speak for my noble colleagues on these Benches, but it seems to me right that someone who would be openly classified as a supporter of this Government should rise to say thank you to my noble friend for his statement, which finds support not only on the Benches opposite or on the Lib Dem Benches but, I presume, on these Benches also. I say that as someone who has actively taken part in the proceedings thus far.
	My personal view is that this House owes a debt to the Minister. I would guess that it was not necessarily the case that all of his colleagues immediately jumped to the same conclusion as him, but he jumped to it having listened to the debate last week. We should express our appreciation not only for the fact that he jumped to that conclusion but for the tone that he has set in delivering it. If that tone prevails during the rest of Committee we will all be the better for it and, much more importantly, the country and the National Health Service will be the better for it.
	I have one substantive comment to make to my noble friend. None of us will want to question in any way the professional expertise of the legal profession. I am sure that it is to the benefit of the House that legal minds apply themselves to trying to find a way forward that would be broadly acceptable. I say gently to my noble friend that this is also about medicine and the delivery of medical care and, if he would permit me to use a not very fashionable word, it must also be seen in a political context. Those are aspects of the deliberations which I hope that he will bear in mind, and not simply adhere to the consensus legal opinion, no matter how good or persuasive it may be, before that is tested in both the medical and the political world.

Baroness Jay of Paddington: My Lords, as one who has been involved peripherally in the discussions over the past few days with the Minister, I follow the noble Lord, Lord Mawhinney, in paying tribute to the Minister for his great patience and courtesy in the number of times and the way in which he has sought to talk to everyone involved in this.
	Further to the question of my noble friend Lady Thornton and the noble Baroness, Lady Williams, in exactly what form would the Minister see further discussions taking place? Several Members of the House have referred to the possibility of the Constitution Committee-which, as the House knows, I have the privilege of chairing-taking this up again. There have already been informal discussions in private sessions of the committee about ways in which we might take this forward. It would be helpful if we could have some indication of how the Minister sees that happening and how it may develop. I very much take on board the points made all around the House about the way in which the Bill as a whole, not simply this clause, has been discussed and how helpful that has been.

Baroness Tonge: My Lords, I am sorry to create just a small ripple in the sea of calm and tranquillity that represents this Chamber this afternoon, but I follow on from what the noble Baroness just said and ask: is there no procedure that we could adopt which would bring the decision of the House on this matter of the duty of the Secretary of State to provide health services back before Report? Report will not be for two months, perhaps, by which time we will have been discussing all the other issues in the health service in a sort of vacuum. How can we discuss all the things that we want a health service to do if we do not know whether the Secretary of State is going to have a duty to provide them? It seems rather odd that we are putting the cart before the horse, or whatever the correct analogy is. This is an important matter. I feel very strongly that we should know as soon as possible whether the Secretary of State will have a duty to provide health services in this country. If we do not have that reassurance, we will have not a National Health Service but a national health shambles.

Lord Newton of Braintree: My Lords, I say gently to the noble Baroness that I had understood that the whole purpose of the proposal made this afternoon by the noble Baroness, Lady Williams, was to give us a chance to look at all the practical issues in the Bill before returning to this umbrella of principles. I can see that one could argue it either way. I have no more right to speak on behalf of my Benches than my noble friend but I share his views entirely and, indeed, I expressed them last week. What is being proposed must be the right way to proceed. It has consensus support around the Committee and I think that we should get on with it and let the Minister explain how he will conduct the discussions. Let us just leave it there.

Lord Warner: My Lords, perhaps I may intervene briefly not in any way to damage this positive outbreak of peace but to make a practical suggestion. Much of the Constitution Committee's report turned on the judgment of the noble and learned Lord, Lord Woolf, in the Coughlan case.

Baroness Jay of Paddington: My Lords, I must intervene on that point. That is only the secondary point of the report.

Lord Warner: Perhaps I may be allowed to deal with it, whether it is the first or secondary point-I do not have the report with me. The point that I wish to make is that we have the noble and learned Lord available to us in this House. If we are to have some arrangement to consider how we go forward on this, I think that it would be sensible to discuss the matter with him because he has sat on cases where the role of the Secretary of State has been a key factor in the courts.

Lord Greaves: My Lords, I discovered at the end of last week that it is possible to table an amendment as part of a group if the debate on that group has been adjourned and the first item in the group has not been put to the House. I did not know that that was possible until I asked. We can all do something new every day in your Lordships' House. Therefore, I put forward a small amendment to question the use of the word "ultimate" in relation to the Secretary of State's powers. My noble and learned friend Lord Mackay very kindly responded to that before I had a chance to speak to it.
	I picked up this issue following comments made last week by the noble Lord, Lord Harris of Haringey, concerning "ultimate". I went home, looked at dictionaries and did my own research, as did my noble and learned friend. I looked in the most recent and biggest dictionary that I could find, which was the Shorter Oxford English Dictionary. I also looked online, as one does nowadays, and spent a happy time looking at what online dictionaries say. If I can gently tease the noble Baroness, Lady Thornton, it is a much better exercise than looking at Twitter, if I may say so.

Noble Lords: Oh!

Lord Greaves: My Lords, I am not going to reveal all my researches and enlighten the Committee on the meaning of "ultimate", except to say-

Baroness Thornton: Perhaps I may say to the noble Lord that I very happily follow him.

Lord Greaves: If the noble Baroness wishes, I shall put lots of information about the word "ultimate" on the Labour Lords' Twitter account. It might enlighten people more than some of the stuff that has appeared. I say all that gently and in a teasing way. I am now quite convinced that there are difficulties with this word and I merely promise the Committee that, if it reappears on Report, I shall be probing it again.
	I thought that my noble friend Lady Williams of Crosby made a wonderful speech this afternoon. If we can get this right, it will do two things. First, it takes out the really difficult sting of part of this Bill. There are other issues in the Bill-I understand that, and we will debate them-but this particular issue threatened to wreck the Committee stage by setting it off on an entirely wrong note. If we can get this right it will help us in the next 12 sittings to have a proper Committee stage and not just political arguments.
	The second point is that the wording, which was in the amendment tabled by my noble friend Lady Williams, from the present legislation has lasted for well over half a century-more than 60 years in fact. If it needs updating-50 or 60 years after the health service was founded-we need to find wording that will last another half a century as the basis for a publicly funded, publicly provided, available-to-everybody health service.

Lord Marks of Henley-on-Thames: These amendments have presented your Lordships' House with a very difficult task. I join others in paying tribute to my noble friend the Minister, my noble and learned friend Lord Mackay, and to the noble Baronesses, Lady Thornton, Lady Williams and Lady Jay, for the wisdom they have shown in proposing to withdraw their amendments today.
	I shall take just a moment or two of your Lordships' time, if I may, to say why I think these amendments present the Committee with such a difficult task. The point was made by the noble Baroness, Lady Jay, in her speech last week. The central feature of this part of the Bill is to transfer, by Clause 10, the duty under Section 3 of the 2006 Act to provide the specific services carried out by the NHS from the Secretary of State to the commissioning groups. The challenge that we now have to meet is to achieve a balance between ensuring a decentralised structure and retaining a truly National Health Service for which the Secretary of State has ultimate responsibility. Given that transfer of provision, what the Secretary of State has to do-and all he can do-is to exercise his functions specifically accorded to him by the Bill. He has to exercise them in such a way to ensure that services are provided, however Clause 1(2) is ultimately worded, and to fulfil his duty under Clause 1 to promote a comprehensive service. That is why the crucial task of this Committee is to look at those functions and ensure that his functions and powers are up to the task and meet that balance.
	A further point that I see as being of considerable importance are the proposed duties to provide autonomy by the Secretary of State under Clause 4 and on the board under the new Section 13F introduced by Clause 20. The problem is that the autonomy provisions in the Bill threaten to undermine the Secretary of State's primary duty to secure the provision of services. We have to deal with what is at best tension and at worst inherent conflict between the Secretary of State's overall responsibility, however expressed, and the duties to promote autonomy. That conflict must be expressed when we come to it, whatever we do about Clause 1(2).
	I have some confidence that your Lordships' House and the department will be able to achieve consensus and I remind your Lordships that not only have we heard from Labour, Liberal Democrat and Cross-Bench Peers in favour of amending the Bill as presently drafted, we have also heard from my noble and learned friend Lord Mackay and from the noble Lords, Lord Newton and Lord Mawhinney, both former health Ministers, who yield to no one in their commitment to and understanding of the NHS. There remains much to be done but I suggest that there is reason for optimism that we might achieve a resolution of all these issues that is effective in helping to secure the future of the health service.

Earl Howe: My Lords, this has been an excellent debate. It has proved one thing in my mind: an issue of this importance for the Bill-the overarching duty of the Secretary of State for the NHS-has benefited enormously from having a Committee of the Whole House to consider it. Without unnecessarily detaining the Committee, I hope it will be helpful if I say something on the record about each amendment.
	I begin with Amendment 3, tabled by my noble friend Lady Williams, the noble Lord, Lord Patel, and the noble Baroness, Lady Thornton, and Amendment 5, tabled by the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt. Both amendments would have the effect of restoring the Secretary of State's current duty to provide services in Section 1 of the National Health Service Act. There has been extensive discussion of this both today and at Second Reading, so I shall not recap all the arguments. The core argument is that the duty to provide no longer reflects the practical reality of how NHS services are delivered or our proposals for the Secretary of State's functions in the new system.
	Before I explain further, I should make clear that we are now discussing the Secretary of State's relationship with NHS services rather than his duties in relation to public health, where his direct responsibilities for provision remain firmly in place. In that context, I refer noble Lords to Clause 8 of the Bill. While I understand that many people are attached to wording that dates back to the founding Act of 1946, it is now more than 20 years since the Secretary of State had any direct responsibility for the provision of services. Only a tiny minority of NHS services-those still provided by PCTs -are carried out under the Secretary of State's delegated function of providing services. In future, all NHS services will be provided by NHS trusts or foundation trusts, both of which have their own self-standing powers to provide services and do not rely on the Secretary of State's duty to provide under Section 1(2), or by independent providers. The Secretary of State will have no powers to provide NHS services. That is the reality.
	I am grateful to the noble Lord, Lord Warner, and to my noble friends Lord Newton and Lady Cumberlege for their persuasive arguments articulating the need to reflect this reality in legislation. As my noble and learned friend Lord Mackay helpfully explained, the Secretary of State has never had an unqualified duty to provide services; he has had a duty to provide or secure the provision of services. In recent years he has relied on the latter part of that duty to fulfil his functions, while the former part has ceased to have any practical relevance. I hope that that answers the question posed by the noble Baroness, Lady Jay.
	There is another reason why it would be wrong to reinstate the duty on the Secretary of State to provide. Under the legal framework of the Bill, the Secretary of State no longer possesses powers to direct others to provide services. Therefore, unless we were to re-impose a system of regulations or directions by which the Secretary of State could delegate his duty to provide and control its exercise, which would risk replicating the micromanagement of the status quo, it is hard to see how this legal obligation to provide services could be fulfilled. For obvious reasons, it would be undesirable to create a situation in which the Secretary of State provided services himself. Also, in practice he would lack the capacity to do so, for example in terms of staff and facilities.
	Instead, the duty we propose in the Bill is a more accurate reflection of what Ministers do. In line with policy that has evolved over two decades, the Secretary of State will not provide services or directly manage providers; nor will he have the powers to do these things. Instead, providers will be regulated independently. Rather than intervening in day-to-day decisions by local providers, the Secretary of State will have powers to hold to account the regulators, Monitor and CQC, for the way that they are performing their functions, and powers to hold the NHS Commissioning Board to account for the way that services are commissioned. In other words, the Secretary of State-

Baroness Scotland of Asthal: My Lords, I hesitate to intervene on the noble Earl, who knows I hold him in the highest possible esteem, but I think he is now treading on some contentious legal issues. Bearing in mind the wonderful consensus that we have now reached, I would just ask him to consider whether, at this stage, some of those issues are really helpful because the noble Earl will know that the Secretary of State does, by his servants, agents or otherwise, provide services and, indeed, there have been times when there has been a pandemic when the Secretary of State has had to make such provision. These are contentious issues which I am sure could intrigue us for many hours, but since we have happily come to the conclusion that we have had a surfeit of such happiness and wish to go forward, I gently say to the noble Earl that this might be a moment when we could swiftly do that.

Lord Lester of Herne Hill: My Lords, I would not have intervened otherwise, but I respectfully disagree with what the noble and learned Baroness, Lady Scotland, has just said. I am finding it very helpful to listen carefully for this reason: it seems to me that the Secretary of State must have a duty to secure the provision, as has been said by the Minister, for the purposes of giving effect to our international treaties, including those on human rights. Therefore, what he is saying at the moment is very important to me in trying to see how one can get wording that will include that as well.

Earl Howe: I am grateful to my noble friend. I apologise to the Committee. I had thought that it would be helpful if I commented on each amendment for the sake of the record so that, going forward, the Government's view of each amendment would be clear.

Baroness Thornton: The reason I did not make my 12-minute speech was that we are now going to go into a period of consideration. I respectfully say to the Minister that we could start the whole debate all over again if he continues telling us what the Government do or do not believe on this because that is presupposing, and possibly pre-empting, the discussions that we are about to have. The noble Lord may find it useful, but we have had a lot of this discussion. We have now, I thought, agreed to move into discussions outside the Chamber.

Earl Howe: I shall, of course, be guided by the Committee. If it is the wish of the Committee that I do not explain the Government's view, then I will not do so. With apologies to those noble Lords whose questions I am not going to answer now-

Lord Harris of Haringey: I appreciate that the noble Earl is moving to a position of not addressing those questions, but it is important that he tells the Committee whether the Government have a fixed mind on these matters or whether they are going to approach with an open mind the discussions that we, in an outbreak of consensus, have agreed should happen and try to build on that consensus. If the views are closed, it raises some very difficult issues for the Committee.

Earl Howe: No, my Lords, there are no closed views. That is the reason why I suggested earlier that it was time to reflect and engage in discussions in the spirit of co-operation. I would not have said that if I had had a closed mind to them. There would not have been any point in the discussions. I simply wished to do noble Lords the courtesy of answering their questions and addressing the points that they had made. If noble Lords would rather that I did not do that, then we can make life easier for ourselves. I will certainly write to noble Lords if they would like to inform me afterwards that they wish to receive a letter. If they do not, I will not write. It is entirely up to them. I do not wish to make work for myself unnecessarily.
	I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters. I would just say to my noble friend Lord Marks that that includes the issues that he has helpfully raised this afternoon. I believe that he is right to associate Clause 4 in particular with the matters that we have been considering. Those discussions can be carried out in an informal way with interested Peers or in individual meetings in the House or my department. There is a place for either type of discussion. My concern is only that it is an inclusive process involving Peers from all sides of the House, and that will include listening to the views of the Constitution Committee should it choose to continue its valuable role.
	With that, I hope that no noble Lord will feel cheated by the brevity of my contribution and I shall sit down.

Baroness Williams of Crosby: I am happy to withdraw my amendment given the statement made by the Minister. I also join the many people in this House who have said how much we appreciate his almost unending patience with us and his willingness to listen and engage in extremely informed and very intelligent debate. It gives me pleasure on this occasion to withdraw the amendment.
	Amendment 3 withdrawn.
	Amendments 4 moved.
	Amendments 4A (to Amendment 4) not moved.
	Amendments 5 and 6 moved.
	Amendment 7
	 Moved by Lord Beecham
	7: Clause 1, page 2, line 7, at end insert-
	"( ) For the purposes of this Act "the health service in England" is defined as those services provided under section 3 of this Act."

Lord Beecham: My Lords, I rise to move this amendment in my name and those of my noble friends Lady Thornton and Lord Hunt of Kings Heath. As we make steady progress through this Bill, your Lordships will encounter many amendments more elegantly drafted than this one, I have to admit. Given the evident affection in which lawyers are held in your Lordships' House, I trust that this member of the junior branch of the profession will be forgiven for the drafting of this amendment, especially as I was not responsible for it-

Baroness Thornton: You are.

Lord Beecham: But I did subscribe to it. There is a sort of collective responsibility on these Benches, too.
	This is a probing amendment-it could hardly be anything else in the circumstances-that tries to deal with what actually constitutes the health service. Of course, this phrase runs through the Bill but there is not within the Bill a definition of what constitutes the health service, let alone "a comprehensive health service"-the words used in Clause 1, which we will be returning to on Report. The amendment seeks to add to Clause 1(3) and the intention is to reflect Section 3 of the 2006 Health Act, which laid out clearly, to a reasonable extent at any rate, the scope of the Secretary of State's duties. The Secretary of State was obliged to,
	"provide throughout England, to such extent as he considers necessary to meet all reasonable requirements"
	broadly six categories of service, amplified in Schedule 1 to the Act by more detailed requirements around medical inspection for pupils at schools and issues of that kind.
	It clearly is impossible to lay down in legislation everything that might be brought within the purview of the Secretary of State or indeed any other body for the purposes of defining precisely what a national health service should be and what would constitute a comprehensive health service. Clause 10 in any event transfers some of those responsibilities to commissioning groups, as the noble Lord, Lord Marks, has pointed out, but it is not entirely clear from the clause, to put it mildly, what functions will be included in their responsibilities.
	The implicit suggestion in the amendment is therefore that at some point it would be helpful to have in the Bill not an exhaustive list, because that would be impossible, given the changes in medical needs and indeed in medical treatments, but an indication of which areas of responsibility for health should be prescribed as areas in which decisions must be made and policies and services delivered by whomever the Bill ultimately vests those responsibilities.
	The need for that, subject of course to the further discussions and debates that will ensue upon the Bill, is enhanced by the possibility-I put it no higher than that-that at the end of the day we might have not so much a single national health service but a series of services that are connected, if you will, and for which ultimately there will be responsibility at some level as yet to be determined, rather than a simple broad national agenda.
	In any event, it would clearly be wrong to make a provision that would restrict the service to any particular list of functions laid down at this time. It would need to be possible to extend that list to meet changes in circumstance, and that would clearly be a necessary condition of any move to create a more visible account of what the service should be about. We on this side of your Lordships' House are certainly looking to see the National Health Service as a comprehensive national service that is comprehensive in the sense of being accessible to all citizens but not necessarily providing every conceivable medical treatment for every conceivable medical condition.

Lord Newton of Braintree: Will the noble Lord explain what he actually wants, because I am now thoroughly confused? First, he seeks the reincarnation of a section of the 2006 Act, which, if I remember rightly, was a consolidation Act-in other words, merely a record of what had already happened in history. He then goes on to say that he does not want to ossify-although he did not use that word-the service; he wants flexibility but accepts that it is not possible at any one time to define everything that the service provides. I simply do not know what he is saying.

Lord Beecham: My Lords, I am saying that the Bill should lay down at this stage a range of services that will be part of a national health service but that that should not be limited by reference to a particular moment. There will have to be flexibility, but the Bill should clearly indicate, as the 2006 Act did, areas that, taken together, constitute a national health service. It is a simple enough proposition. The content would have to be debated as we go forward, but this is a probing amendment that is designed to ventilate the issue in the hope that some consideration might be given in the course of proceedings on the Bill to the changes that are required.
	Ultimately, some decisions will have to be taken about what services are to be provided, not least about the services in Clause 1(3) that must be provided free of charge. People are entitled to know what services they will get free of charge at any given time. As I have said, at some point these matters should be elaborated. There is also an issue about how public health services are to be regarded in the light of the Bill's current proposals; for example, in relation to the role of Monitor, competition issues and the like.
	Amendment 7 seeks to establish a method of taking this discussion forward so that all of us may be clearer about what we are entitled to expect of a National Health Service and, for the purposes particularly of new Section 1(3) of the National Health Service Act 2006, what services would be provided free of charge. I hope that we can look at that matter and perhaps return to it on Report. In that light, I beg to move.

The Earl of Listowel: I thank the noble Lord, Lord Beecham, for moving this amendment and for giving us an opportunity to discuss a definition of the services of the National Health Service. Perhaps the Committee will forgive me if I make now the arguments that I had hoped to make in the later debate on mental and physical health in the health service, for which I am unable to be present. Those arguments are also pertinent to this amendment.
	I seek reassurance from the Minister that the new arrangements for the health service will have a specific duty to focus on support of the relationship between the parent and the child, or whoever is acting in loco parentis for that parent, particularly during the early years and in adolescence. Professionals say that adult mental health hinges on the relationships between the primary carers and the child in early life and in adolescence.
	The Government's White Paper highlighted that mental health is important to public health. It follows that in the future we have to be even more careful to ensure, without being overly intrusive, that the relationships between parents and children in the earliest years and in adolescence are as supportive as possible. The health service should have an important role in that. For instance, there is tremendous pressure to generate more early years nursery places. In a recession, we want parents to work and to help build capacity. Nurseries need to be cheap, yet we know that high-quality early years intervention is crucial to better outcomes for children. We also know that the people who work in those settings are often underpaid and not properly supported, and that there can be a high turnover of staff. In driving people, for understandable reasons, to use nursery provision more, there is a danger that the relationship between the parent and the child could be undermined.
	The evidence indicates that high-quality early years education produces better outcomes in school for children. Professor Jay Belsky at the University of London investigated this issue. Exposure to poor-quality early years education and nursery care over a number of years can have serious, although small, deleterious effects. But if a lot of children go through these experiences, the overall impact can be significant. It is very hard to measure-this is probably why it does not get prioritised enough-what difference it makes if there is not sufficient support for relationships between parents and children in the earliest years and in adolescence. It is easy to measure cognitive performance in schools, whereas the relationship between parent and child in the earliest years and adolescence is hard to measure. However, qualitatively I am very clear, after consulting with colleagues in the mental health profession, that it is hugely important to get that support right.
	I know that the Department of Health works closely with early years services to try to offer such support, but there are still shortcomings. For instance, there is not sufficient support in adult mental health services for adults as parents in children's centres, and more work could be done. An old chestnut is that, if a parent is presenting with mental health issues, thought is not always given to the fact that the parent has children who will have needs. If a parent is mentally ill, what are the mental health needs of the children? Again, if a child presents with mental health problems, a proper assessment needs to be made to look at whether perhaps the best input is to support the parents. That may help the child to get better.
	Noble Lords will be pleased to know that I will not say much more. A few years ago I remember working with a young man who was just coming out of adolescence. His father was an alcoholic and he had experienced domestic violence in his home. I was seeing him and working with him once a week for six months. The issues he had were that he was experiencing growing paranoia, he was fearful and distrustful of the staff, he was mercurial and unpredictable in his behaviours and he had a difficult relationship with women. If there had been better support for that family, perhaps the nascent problems we saw at the time could have been nipped in the bud and he would not have had those difficulties.
	I am sorry if I am not explaining myself sufficiently clearly, but I would be grateful if the Minister could reassure the Committee that in any of the new arrangements there will be a particular focus on getting in early to support families, both parents and those acting in the role of parents, in their relationships with their children to make sure that those relationships are strong. Children will then have a good basis from which to grow and enter adulthood. I hope that that will be a priority in the new arrangements.

Earl Howe: My Lords, Amendment 7, tabled by the noble Lords, Lord Beecham and Lord Hunt, and the noble Baroness, Lady Thornton, seeks to set out a new definition of the health service in England as,
	"those services provided under section 3",
	of the 2006 Act. While I know that the noble Lord has the best interests of the NHS at heart, I fear that this amendment might achieve the opposite of what he intends because its effect would be to narrow the definition of the health service.
	Section 3 of the NHS Act 2006, as amended, will set out the services that clinical commissioning groups will be required to commission, including, for example, maternity services, hospital accommodation and, in answer to the noble Earl, Lord Listowel,
	"such other services or facilities for the care of pregnant women, women who are breastfeeding and young children as he considers are appropriate as part of the health service".
	Defining the health service as meaning only those services set out in this section would limit the application of the provisions of the Act, excluding other vital parts of the health service that are not defined in Section 3. For example, that definition would exclude primary care and specialised services, which would be commissioned by the NHS Commissioning Board, and public health services, which would be provided or commissioned by the Secretary of State or local authorities. Clause 1(1) of the current Bill retains the Secretary of State's duty to promote a,
	"comprehensive health service designed to secure improvement ... in the physical and mental health of the people of England, and ... in the prevention, diagnosis and treatment of illness".
	This clearly sets out what the health service must do. Any attempt to define it more precisely might have the perverse effect of leading to an NHS which delivered fewer services.
	I can assure the noble Lord that services commissioned by clinical commissioning groups will be covered by the wording of the unamended clause, and thus these services will be covered by the Secretary of State's duty to promote the comprehensive health service. As part of the health service, those services must remain free of charge. Clinical commissioning groups will be responsible for commissioning the services listed in Section 3 of the 2006 Act such as hospital services and maternity services. They must arrange those services, although as with primary care trusts at present, Section 3 will permit them discretion to determine precisely what services are necessary to meet the reasonable requirements of their local population. The Commissioning Board will issue commissioning guidelines and monitor the commissioning activity of CCGs with a view to ensuring that no essential services go uncommissioned in any given locality.
	I say again to the noble Earl, Lord Listowel, that we will consider mental health issues in a later amendment tabled by the noble Baroness, Lady Hollins, and I will be happy to cover the issues around the parent/child relationship then. However, I agree very strongly with the point the noble Earl made about the importance of the parent/child relationship. In a nutshell, our reforms are aimed at empowering patients, including their families and carers, and the Bill provides a strong footing for that relationship to be strengthened.
	I can assure the noble Lord, Lord Beecham, that this is not the Secretary of State washing his hands of the NHS. The Secretary of State will retain-at the risk of reopening the previous debate-ultimate accountability for promoting the comprehensive health service. The Bill gives the Secretary of State extensive powers of oversight and stewardship of the NHS. His powers include the power to prescribe, in the standing rules regulations under proposed new Section 6E of the 2006 Act, inserted by Clause 17, that CCGs must commission specified services.
	I think the noble Lord suggested that the 2006 Act was clearer about what the health service was and that this Bill makes it less clear. The Bill does not reduce the clarity of the 2006 Act in terms of a description of the services which must be provided as part of the health service. Section 3 and Schedule 1 remain in place so far as the services covered are concerned; it is simply the identity of the body responsible for arranging them which will change.
	The noble Lord asked what was wrong with an illustrative list. There is already an illustrative list in Section 3 of the NHS Act 2006 which, as I have said, sets out the services the CCGs will be required to provide. However, attempts to define that list more precisely will inevitably lead to the problems that I have outlined. I hope that reassures the noble Lord that the existing definition is satisfactory and that he will withdraw his amendment.

The Earl of Listowel: I thank the Minister for providing me with the strong assurance that to him and his colleagues the strengthening of the parent/child relationship is absolutely crucial in what they are doing. There is strong agreement with that point and I thank him for that. I will look forward to reading with interest in Hansard the later discussion on mental health.
	The Minister mentioned the availability of essential services. To highlight the current concerns, an effective and well respected foster care charity operating in all the nations of the United Kingdom had to create its own child and adolescent mental health services in Wales because there was so little available in that nation. On children's homes, it has been recognised for a long while that often our most vulnerable children are placed in children's homes with staff who are poorly equipped to meet their needs. There have been important steps forward in improving that situation but, crucial to that, is ensuring that those staff get the mental health support they need. That is becoming more widely available over time, but it is still piecemeal. We need to ensure that those kinds of situations do not continue into the future.
	I am grateful for the Minister's assurances about the Government's priorities in this area and, as I say, I look forward to reading the debate in Hansard.

Lord Beecham: My Lords, I am grateful to the noble Earl, Lord Listowel, for once again bringing his expertise on this issue. He is perhaps the leading proponent in your Lordships' House of the concerns around children's health and other matters relating to children, and his contribution today certainly falls in line with our experience of his many contributions in that area of policy.
	I am also grateful to the Minister for his reply. I did not, and the amendment does not, suggest that we should have an exhaustive, finite list of responsibilities or functions which comprise the National Health Service. That would clearly be inappropriate. I thought I had made that clear but perhaps failed to do so. The noble Lord rightly pointed out that, under Clauses 10 and 11, responsibilities are effectively transferred from the Secretary of State to clinical commissioning groups. Had this amendment been taken forward, it would have identified for those groups the services which they should carry out. Of course, the transfer imposes the duty to arrange for the provision of services to the extent that each commissioning group considers necessary. That provision raises the question of the extent to which there is still a commonly accepted view of a National Health Service. That is an open question that we will no doubt return to in different forms as we go forward, but in the circumstances I beg leave to withdraw the amendment.
	Amendment 7 withdrawn.
	Amendments 8 to 8A not moved.
	Amendment 8B had been withdrawn from the Marshalled List.
	Clause 1 agreed.
	Clause 2 : The Secretary of State's duty as to improvement in quality of service
	Amendment 9
	 Moved by Baroness Thornton
	9: Clause 2, page 2, line 12, after "service" insert "by providing services or making arrangements for others to provide services"

Baroness Thornton: My Lords, I will also speak to Amendments 10 and 14. The purpose of these amendments is to strengthen the responsibilities of the Secretary of State for improving quality by changing the requirement to act with a view to reducing inequalities to providing services or making arrangements for others to provide services that ensure an improvement in quality. Furthermore, in the light of Clause 1 removing the Secretary of State's role in providing services-although we still have that matter to resolve-it probes the extent to which the Secretary of State might be able to effect an improvement in the quality of services.
	In general, we would welcome and support an explicit duty being placed on the Secretary of State to improve quality-of course we would. The grouping of these amendments has two components. First, it makes the point that quality and inequality affect communities as well as individuals, so planning must be on a geographically defined basis. Secondly, there are amendments designed to make the Secretary of State more directly rather than indirectly accountable-that goes back to the Clause 1 argument again. Amendments 9 and 10 tighten up the Secretary of State's duties. As amended, the provision would state that the Secretary of State must exercise the functions of the Secretary of State in relation to the health service by providing services or making arrangements for others to provide services to secure continuous improvement in the quality of services provided. This mirrors the changes that we have argued for in relation to Clause 1, to make the Secretary of State more directly responsible rather having responsibility at one stage removed.
	As I am sure the noble Baroness, Lady Finlay, will explain to the House, the amendments in her name are also important. This is the first time-but certainly not the last-that the idea is introduced of responsibility for an area-based population. The amendments acknowledge that quality and inequality affect communities as well as individuals. We support this idea of area-based responsibility and will later seek clarification on how basing some commissioning on GPs can be reconciled with the need to plan for geographical populations. Indeed, Amendment 14 is on the same theme, making the Secretary of State directly responsible and going back to that formulation of provision as opposed to being one step removed. As amended, the provision would say that in discharging the duty under subsection (1) of the proposed new Section 1A of the 2006 Act, the Secretary of State must either provide services that ensure, or make arrangements to ensure continuous improvement in the outcomes that are achieved. Actually, the amendment is defective because the word "must" has to be left in.

Lord Mawhinney: I am extremely grateful to the noble Baroness, but she skated over what an area-based population is. Presumably, if the Secretary of State has responsibility for individuals he has responsibility for a lot of individuals who happen to live cheek by jowl to each other. I am sure that it would be helpful to the Committee-and it would certainly be helpful to me-if she told us what an area-based population is or might be.

Baroness Thornton: The amendments that open the debate are in the name of the noble Baroness, Lady Finlay, so I suspect that she will also take the opportunity to explain that to the Committee. However, I think that we will have several debates as we move through the Bill that are about the concerns that some of us have if the commissioning of services is based on GP lists and not on a population in an area. What this probing amendment seeks to do is to help to open up that discussion about how you make sure that there are not people in an area who may not be on a GP list and who fall through the cracks in terms of health provision in that area.
	This series of amendments seeks to do two things. One is to raise the point about equality and inequality as it affects communities as well as individuals. For example, the provision of family planning services in an area affects an area as well as the individuals who make use of the services, and you would indeed plan those services. That may not be a good example because of course that is public health, but I think that the Minister will see that you have to look at how you plan services in terms of not only the individuals but the needs of an area.

Lord Newton of Braintree: I am sorry to interrupt, and this may be another question for the noble Baroness, Lady Finlay, but what is a primary care trust if it is not concerned with the population of the area as that primary care trust is defined? This all seems to me like gobbledegook.

Baroness Thornton: My Lords, it is about the people in the area-but of course primary care trusts are going to be abolished by this Bill.

Lord Newton of Braintree: The noble Baroness said that this was the first time that we had had area-based planning, but a primary care trust is an area-based entity, planning for the population of an area.

Baroness Thornton: I think that the noble Lord misheard me. I said that it was the first time that we had discussed this in the process of this Bill. I beg to move.

Baroness Finlay of Llandaff: My Lords, I shall speak especially to Amendments 10A, 10B and 11A, and address my remarks principally to Amendment 10A, whose aim is to avoid fragmentation and inequity through a loss of contiguous, coterminous and comprehensive area-based structures for healthcare resource allocation planning, commissioning and service co-ordination. The amendment would ensure that the sensible changes that were just agreed today over GP contracts for this year are carried forward into GP consortia arrangements. The Secretary of State, Andrew Lansley, himself discussed issues around area-based practice at the congress for the Royal College of General Practitioners last month, and had a fairly extensive and open discussion with the GPs there on this topic.
	I move to the Bill as it stands. I hope that with some of the background discussions that have been happening, my amendment will not just be dismissed and will be quite seriously considered, because it might solve a problem.
	In the Bill, the new commissioning consortia's duty-

Lord Mawhinney: I am sorry, I may be the only person in the Committee who is thick enough not to understand what is going on, but I have to say that I do not. I asked the noble Baroness, Lady Thornton, to define something that she said she was in favour of, which was area-based entities, but she palmed that off on to the noble Baroness, Lady Finlay. I would be grateful if she would define what an area is. Is it a county, a city, a town or a village? Is it the north-east or the south-west? Who in the context of this Bill does she see as having responsibility for defining the area and addressing the issue in the area?

Baroness Finlay of Llandaff: I would be grateful if the noble Lord would bear with me for a couple of minutes while I go through a few paragraphs and try to explain how this clause poses some problems, because I agree that it is pretty complicated.
	The new commissioning consortias' duty in the Bill is to arrange for health services provision that applies to those enrolled patients registered with them. This contrasts with primary care trusts, and the other structures that will be disbanded when the new structures come in, because the population of the consortia will be drawn from the patient lists of member general practices rather than from residents living within a defined geographical area. That means that as clinical commissioning groups they will have the freedom to choose who they take on to their registers, regardless of where they live. As a consequence, the population for which a clinical commissioning group is responsible may include not all individuals and families living in the local area, so may not represent an area-based population. However, it may have some people whose primary residence is a long way away but who decide to register with a GP because that is where they work and where they are during the week.
	It has been suggested that individuals and families who are not enrolled within a local commissioning group's general practitioners may not be covered and would therefore need to be covered by a small number of more centralised clinical commissioning groups, which will effectively mop up those individuals and families who lack membership within a local clinical commissioning group. I would therefore be grateful if the Minister could confirm the arrangements for those patients, such as people who are homeless, and who may for whatever reason not be on a particular general practitioner's list. Can he also explain to the Committee how these patients will be allocated to receive primary medical care services since that allocation duty currently falls to primary care trusts, which will not be there in the future? The services will be designated from the commissioning board, which is at quite some distance from patients who do not have a GP and from individual GPs.
	The combination of removing geographical responsibility for the provision of healthcare, together with the removal of practice boundaries, creates a number of risks: an inability to plan for local services; a risk of worsening health inequalities and social segregation; and fragmentation between social care and healthcare-the former being based on local authority boundaries and the latter then being based on a potentially England-wide catchment area, depending on who registered with a GP. Allocating resources based on the GP-registered list rather than any geographical population will mean that there would not be coterminosity with public health-or, importantly, with local authority services, which are responsible for much social care and for the safeguarding of children and vulnerable adults. A lot of those responsibilities for safeguarding held by a local authority relate to the geographical area of a local authority.
	With GPs potentially competing for patients across the whole country there could be fragmentation, especially if someone registers near their place of work as when they are ill they are likely either to be at home or to return home, which may be many miles away. They may need services at home, particularly medical and nursing care, if the condition is sufficiently serious to require them. Yet the GP with whom they are registered for primary medical services would then be at a distance that would make home visiting impossible.
	In April of this year the Health Select Committee emphasised the importance of aligning care to geographical boundaries, making this point:
	"Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities".
	To paraphrase that, I hope that my amendment is in line with the recommendation of the Health Select Committee.
	The local authority will take over many functions of current PCTs, especially over safeguarding, as I said. This is important, particularly for children who are unable to transfer their own care. Different children from the same family who are at particular risk and on an at-risk register will potentially be registered in different places by abusive parents who deliberately want to ensure that they limit, or almost exclude themselves from, surveillance. I am sure I do not need to remind the House that the tragedy of Baby P was an example of a parent who avoided surveillance and, tragically, avoided it far too effectively.
	The other difficulty is that there are families who have very complex lifestyles, with different members registered at different distances, particularly if they are mobile families. This will make it very hard to obtain an overall picture of the health, education and safeguarding services if these are not coterminous. Where local authority, education authority and health provision are coterminous, there is a much better chance of a good transfer of important data on the welfare of these children who are at risk.
	Public health is a major and very welcome focus of the Government. This amendment is also necessary to ensure that the NHS will adequately address those issues of health improvement such as smoking cessation, screening for disease, immunisation and so on, where treating people as a population rather than a collection of separate individuals is more effective. Public health can achieve optimal population health outcomes only if there are area-based organisational structures and frameworks in the health system. That becomes particularly important in more rural areas, as it ensures optimising efficiency, accountability and effectively integrated care.
	The amendment also supports the Secretary of State's responsibility for issues of health protection, such as the control of an epidemic of infectious disease. Such an epidemic cannot be dealt with just by treating individuals. It requires an area-based approach, using vaccinations, population monitoring and so on to ensure disease containment. Additionally, without coterminous working of health and local authority, planning of capacity becomes harder.
	General practice can certainly do much to improve its quality of service in some areas, particularly access to primary care through extended hours, out-of-hours coverage of the population and decreasing the dangers that are encountered with the lone-worker GP who does not have contact with other colleagues. General practice could go towards federated models of practice; that is not incompatible with the spirit of this amendment. However, all these improvements need geographical areas to function properly and drive up quality of care.
	Epidemiological research has been a strength of the UK, building on registers of a precisely defined denominator of patients, categorised by age, sex and so on, and known to be living in a particular environment. Weakening it by multiple registration will break the link of geography with health and may impede the aim of driving up quality. It will certainly impede our ability to carry out effective quality-based research on improving health in the future.
	Another area that I want to address briefly is that of the medical examiners in relation to coronial jurisdictions. Their work depends on them being geographically area-based and seeing the death certificates of all the general practitioners within that area as they come through. There is a concern that if there is wide fragmentation it may be more difficult to pick up trends that should not be there.
	Amendments 10B and 11A seek to delete "or" and insert "and" to make subsection (1) of proposed new Section 1A of the 2006 Act refer to the prevention, diagnosis and treatment of illness, and then go on to public health. I suggest that these amendments are logical as they would ensure that the Secretary of State has a duty to improve all three of those aspects in relation to illness. The measure also emphasises the importance of public health in conjunction with the prevention, diagnosis and treatment of illness. I stress that "illness" includes both mental and physical illness.

Lord Walton of Detchant: My Lords, my noble friend has, as always, been extraordinarily persuasive in her detailed argument in support of her Amendment 10A. I apologise to her and to the Committee for not having discussed it in detail with her beforehand. The intention underlying the amendment is in every way admirable. Amendment 10B, to which she spoke more briefly, deserves a great deal of attention and would greatly improve Clause 2 of the Bill. My only concern with her remarks about area-based populations relates to the definition that would be attached to the clause. New Section 1A(1), as inserted by Clause 2, is defective in my opinion in that it refers to,
	"securing continuous improvement in the quality of services provided to individuals".
	The provision of services in the National Health Service does not relate simply to the treatment and improvement of the health of individuals. As the term "public health" implies, it deals also with the improvement of the health of communities. After all, public health doctors were called community physicians until quite recently. In many ways I would have preferred to see the clause include, after the word "individuals", "and/or communities" to make that position entirely clear. I warmly support the principles underlying my noble friend's amendment but the wording requires a little attention as throughout my professional career I have been very familiar with the hazards that arise in attempting to draft and redraft documents in committees, large and small. I do believe that this matter needs to be given attention by the Minister.

Lord Warner: My Lords, I am not altogether sure whether I rise to support these amendments or not. I promise the noble Lord, Lord Mawhinney, that the phrase "area-based populations" will not pass my lips after this utterance. There is a question which it is apposite that I raise with the Minister under this group of amendments as it has puzzled me for some time. Under the present arrangements, we have a public body called a primary care trust which can cope with a set of circumstances in which people are thrown off a GP's list, have not got onto a GP's list or have a lifestyle which means that they are disinclined to join a GP's list. There is a mixed bag of people. This group of people live in a particular area, however that is defined. It is an area for which, somewhere in the country, a primary care trust is responsible. In the world of clinical group commissioning which is based on practice lists, I am not altogether clear how this group of people are safeguarded.
	I am sure that the brilliant minds of the officials in the Department of Health have thought of this and have a cunning plan that, no doubt, the noble Earl will divulge to us. However, it is an issue that has caused concern, and I do not feel equipped to answer that concern because I am not clear as to how the Government will cope with that group of people.

Baroness Williams of Crosby: My Lords, perhaps I may ask a couple of questions in this short debate and thank the noble Baroness, Lady Finlay, for her comprehensive presentation. This is a difficult area of the Bill. First, what happens with someone whose main residence is in one place but who is actually very dependent on out-of-hours care because of the nature of their job. There must be literally hundreds of thousands of commuters for whom the natural place they would like to go, due to the recollection of personal data and all the rest of it, would be the clinical commissioning group in their home area, but because they spend a great deal of time at work a long way away they will in fact depend on out-of-time services. I am troubled by the low quality of some of those services in comparison to what we might call mainstream NHS care.
	The second question is perhaps easily answered. Can the Minister say something about the relationship of both new structures to NHS Direct? I am not clear as to whose responsibility NHS Direct will be. Will it continue as a kind of separate freewheeling service or be linked to a clinical commissioning group; and, if so, at which end of the spectrum would it be linked?

Baroness Murphy: My Lords, I am particularly concerned about the area-based issue because, like many people, I have been banging on for years about the importance of coterminosity between health and social services. However, my experience over the years has been that that has not made much difference to the co-ordination of care between health and social care.
	I want to raise a point about the new arrangements. I understand that we are trying to move away from the old RAWP funding formulation, which has always been deeply unsatisfactory and open to political manipulation, to the funding of real groups of patient populations on a risk-assessment base. To achieve that, there is no doubt in my mind that you must have real people on real lists, whether or not that clinical commissioning group has a responsibility to provide for a population within the group. You must be able to work towards a funding solution for those clinical commissioning groups that reflects real need and moves away from the old area-based populations.
	I think that that may be the response I would give the noble Baroness, Lady Finlay. I did not really understand the brief amendments in this group that were not specifically related to this question so I address my issues to that.

The Lord Bishop of Chester: My Lords, I completely support the amendment in the name of the noble Baroness, Lady Finlay, but wonder whether what she wants could be achieved-it might be a small step in the right direction in relation to legislation generally-by simply removing from the Bill the words "provided to individuals". The term "individuals" has a jarring effect. "Provided to people" might sound a bit better, but "individuals" has a slightly impersonal feel, especially as we are concerned as a Committee and as a House about the "national" character of the National Health Service. References to individuals jar in that regard as well. Simply requiring improvement in the provision of services might achieve what the noble Baroness seeks in her amendment.

Baroness Cumberlege: My Lords, I should like to ask a few questions about Amendment 10A. I thank the noble Baroness, Lady Finlay, for her introduction, but we do not yet have a precise definition of what she means by area-based populations. All sorts of different services have different catchment areas. At the beginning, the noble Baroness cited family planning services. She said that she felt that perhaps it was a bad example, and I think it probably is because there are so many different services that require different boundaries. I am for coterminosity as far as we can get it, because when I was a regional chairman, I saw that where you had coterminosity between the health service and local government, you could achieve a great deal. That worked well, but when one examined it carefully, it was not so much about the boundaries; it was about the relationships built between different people. That was what made the services work extremely well.
	With regard to GP practices, GPs usually want people within their area, especially if they will have to do home visits. I have been in the situation-I am sure that many noble Lords have-where I had an emergency in London but my GP is 52 miles away. That can be coped with; you can still manage that, although it is quite awkward in some respects. My anxiety about allocating patients to different GPs-being neat and tidy and trying to get all the boundaries sorted-is that I do not know what it does for choice. Perhaps the noble Baroness will say something about that. What happens when people want to choose a different GP who is out of their area, which is what we want to do locally but are unable to because the boundaries have been so clearly fixed, I have to say, by the GPs themselves?

Lord Rea: My Lords, the noble Baroness, Lady Finlay, has somewhat stolen my thunder because I had meant to say almost exactly what she said, but I was going to mention it when we got to the part of the Bill describing the clinical commissioning groups. Schedule 2, which relates to clinical commissioning groups, states:
	"A clinical commissioning group must have a constitution ... The constitution must specify",
	the name, the members and the area of the group. That is there. I would like the noble Earl to describe how that area is to be measured and whether it is to be coterminous with existing boundaries, particularly local authority boundaries, for the very reason given by the noble Baroness, Lady Finlay.

Baroness Tonge: My Lords, most of the points I wanted to raise have already been raised so I will not repeat them. I congratulate the noble Baroness, Lady Finlay, on her comprehensive overview of her amendments. What concerns me most is those patients who fall through the net of the new general practice commissioning groups. If it is not area-based and there is not a primary care trust responsible for allocating those patients, where will people who do not speak English very well, asylum-seekers, the homeless, mentioned by the noble Baroness, and Travellers go? What about those patients whom I remember well, whom most GP practices did not want on their lists at all and who were rotated around general practices in order that they got medical treatment? What will happen to all those patients? There are many of them and some of them have severe disabilities and some are severely mentally ill. They fall into all sorts of groups. I am extremely concerned that without an area base or a responsibility on a PCT or a commissioning group to deal with patients in a particular geographical area, those patients will suffer hugely.
	I want to make one final point. The other service that will suffer hugely is our accident and emergency departments, because if those people do not have GPs, that is where they will go. I was a casualty officer in central London for a whole year, once upon a time, and I virtually ran a general practice there then for patients who were unattached to general practices. That problem will increase, and I hope that the Minister will address that in his comments.

Baroness Finlay of Llandaff: My Lords, it may help the Committee if I explain how the GP contract is being renegotiated; I hope that I get this right. Instead of a GP contract covering a rigidly defined area, as now, there will be an outer ring as well. If patients move a bit further away but stay within that outer ring area, instead of being forced to change their GP, they will be able to remain with their current GP. Therefore, I think that the problem of choice, to which the noble Baroness, Lady Cumberlege, alluded, should in large part be solved by the negotiations that the Government have just had with GPs. There is of course a difficulty in defining any area but to date the areas have been defined by GPs, and they will still have to define the outer area or outer ring to which it is practical for them travel to carry out home visits and so on.
	As I understand it, a decision has not yet been taken on what will happen with people who, like most of your Lordships, are classified as temporary residents. Many of us live a long way from here and, if we need to see a GP, we register as a temporary resident with one somewhere in Westminster. I am not sure how those arrangements will work in the future but they have served us reasonably well until now. The danger in relation to allocation relates precisely to those patients to whom the noble Baroness, Lady Tonge, referred-those who have been thrown off GP lists or cannot get themselves signed on to a GP list for whatever reason but still have healthcare needs. If those needs are not met, that will impact on the very social fabric of our society. I hope that I have clarified some of the points.

Baroness Hussein-Ece: I should like to ask a couple of questions to clarify where the debate is going. As my noble friend Lady Tonge said, for a number of years some groups have found it almost impossible to get a GP. It is almost a case of GPs selecting the people they want on their lists; it is an unwritten code. That is why asylum-seeking families, refugee families and others with very high needs will always find it difficult to get a GP, and I want to ask the noble Baroness, Lady Finlay, how her amendment will assist that.
	Equally, as has already been mentioned, areas of high need have in my experience always been in inner cities, where it has been difficult for some people to register with a GP. We know that attendance at A&E departments has become extremely high in some areas-almost unsustainably so-and I want to ask how the amendment will address that too.
	There are also families who are placed by local authorities in temporary accommodation in other areas. Currently, a local authority is responsible for such a family-for example, social services or family support may be involved with the children. However, if that family is placed in another borough way out of the catchment area, I am not sure who their GP will be. Perhaps the Minister can respond to that as well and say how that would work with a local authority having responsibility for a family placed well outside the area. Would that family still be able to get support by going on to a GP list in the new area? Would that connection be made? Over the years we have worked very hard to make sure that social care, healthcare and local authorities all work together in partnership. Perhaps we could have an explanation of how it is going to work when families with very high needs are spread around.

Lord Newton of Braintree: My Lords, your Lordships will have realised by now that I am basically a simple-minded soul. I am struggling to discover what this issue is but it seems to come down to one specific point: do clinical commissioning groups have the same responsibilities as primary care trusts for planning services for all the people that they think live in their area? That is the core question. Do they have an area base-I dare to risk upsetting my noble friend-for their activities? I understand that it has been decreed that no practice can be part of two clinical commissioning groups; they cannot overlap and have to be distinct and separate. In a sense they are the same as primary care trusts. Do they have a responsibility to plan and provide services for all the people known to be in that area? The rest of this is all peripheral. I require services from the NHS both in London and at home in Essex, and I normally get them. But people in Westminster, where my flat is, know perfectly well that there are lots of second homes in Westminster, and presumably the health authorities and primary care trusts know that as well and plan on that basis. It is a simple question: does somebody have a responsibility to plan and provide services for all the people in their area? Yes or no?

Noble Lords: No.

Earl Howe: Yes, my Lords. I hope that I can reassure noble Lords on their very valid concerns on this topic. Perhaps I can say a few general words first of all about quality. The Government's ambition in modernising the NHS is to create a health service that delivers outcomes as good as any in the world. We all know that at its best the NHS is world-class, but we also know that there are important areas where the quality and outcomes of care could and should be improved. If we are to safeguard the quality of services and drive improvement, we must take positive action. We are addressing the structural weaknesses in the system and seeking to embed the principle of quality throughout. This is why the Bill creates a legal duty for the Secretary of State and for the NHS Commissioning Board and clinical commissioning groups to be guided by the need to improve quality in all that they do.
	In doing this we are building on the work of the previous Government under the noble Lord, Lord Darzi, and in particular we are using the definition of quality that he introduced-care that is effective, safe and delivers a good experience for patients. By positioning the quality duty in the context of a duty in Clause 3-to bear in mind the need to reduce inequalities within the population in designing services, particularly the most vulnerable members of society-we intend that these reforms will deliver the vision of high-quality care for all, as he so ably articulated.
	Amendments 9, 10 and 14 place a duty on the Secretary of State to provide or secure the provision of services that in their turn should secure continuous quality improvement. We have already debated at great length Clause 1 and the duty to provide, and I shall not rehearse that discussion again, but I should like to be clear that it is the role of commissioners to drive quality improvements and the role of the Secretary of State to seek to improve quality by exercising his functions. He will do this, for example, through the mandate that he sets for the board, or the outcomes framework which he will issue and to which the board must have regard when it exercises its duty in relation to quality.
	The amendments also place a duty on the Secretary of State to secure continuous improvement in the quality of services. Similar amendments were debated at some length in another place. It was clear throughout those debates that there is extensive and wide-ranging support for the principle that the health service should strive to provide the best possible service to patients. I thank the noble Baroness, Lady Thornton, for indicating her support for that principle. I am sure that we share it. As drafted, the Secretary of State, and in practice the Department of Health, is required to seek to achieve continuous improvement even if external factors mean that in particular cases such improvement may not be delivered. In our view, the clause as drafted should do what is necessary to deliver improvement in the quality of services while not imposing unreasonable or unrealistic burdens on the Secretary of State and the NHS. We believe that this duty, taken alongside those placing the same duty on the board and clinical commissioning groups, and the expectations that the Secretary of State will set through the outcomes framework, already ensures that the principle of securing continuous improvement in service quality is embedded throughout the health service and the wider care system. I hope that I have reassured the noble Baroness, Lady Thornton, of the Government's commitment to the continuous improvement of quality within the health service, and that she will not press her amendments.
	I turn to Amendments 10A, 10B and 11A, tabled by the noble Baroness, Lady Finlay. They seek to strengthen the duty by inserting "and" in place of "or" where the clause lists the areas that the duty to secure quality improvement applies to. The noble Baroness expressed concern previously about the wording. I assure her that "or" is the appropriate word and that we are not allowing the Secretary of State to neglect certain aspects of healthcare when exercising their duty. There is no risk that the courts could misinterpret the unamended clause as meaning that the Secretary of State has to exercise his functions with a view to securing continuous improvement in the quality of services in only some rather than all areas that the Bill specifies.
	The duty refers to quality in respect of services provided to individuals. In many cases, particular services provided to an individual will relate to one or more of the matters referred to in new subsection (1)(a) and (b), but not to all of them. For example, the service may be to prevent or diagnose illness but not to treat. Another service might be to treat but not to diagnose. The use of "or" makes it clear that the duty applies to the quality of all services, whatever the purpose for which they are provided. Although I am certain that it is not the noble Baroness's intention, the use of "and" would inaccurately suggest that the duty could apply only to the provision of services that prevent or treat illness.
	Amendment 10A seeks to extend the duty to improve the quality of services from those provided to individuals to those provided at a population level. Of course it is just as important for public health services to improve as it is for any other sort of health service, but new Section 1A already recognises that with its explicit reference to public health services in subsection (1)(b), which refers to the,
	"protection or improvement of public health".
	The wording is echoed in Clauses 8 and 9, which set out the new public health duties of the Secretary of State and of local authorities.
	Clauses 8 and 9 provide examples of steps that may be taken under those duties and that might therefore be subject to the duty of quality in new Section 1A. They include providing information and advice, for example, as well as preventing or treating illness. This means that new Section 1A already applies to a wide range of public health services. Any public health activity that involves the provision of a service to individuals-albeit that the general purpose is to improve or protect health at a population level-such as vaccination or smoking cessation, would be covered by the duty in the clause as drafted. Of course, improving the health of populations cannot be achieved without improving the health of individuals. I make it clear that some steps may be taken to improve or protect public health under Clauses 8 and 9. These extend beyond services provided to individuals.
	I turn to questions that were raised. The noble Baronesses, Lady Thornton and Lady Finlay, spoke about the importance of commissioning for an area-based population. We completely agree with the general sentiment. That is why CCGs, contrary to the perception of some noble Lords, will commission for all unregistered patients within their geographic area, as well as for those on their registered lists and others to be defined in regulations. I refer noble Lords to Clause 10(3), which is on page 6. It is also why we are establishing health and well-being boards to agree a holistic strategy for their area. That is Clause 190.
	We amended the Bill in another place to clarify that clinical commissioning groups have responsibility not only for patients registered with the GP practices that comprise their membership, but for those usually resident in the clinical commissioning group's area who are not registered with any GP practice. We must also ensure, when we exercise the power to set out other persons for whom a CCG has responsibility, to provide through regulations that a CCG has responsibility for ensuring that everyone in its area can access urgent and emergency care. I turn to my noble friend Lady Tonge, who asked me about that issue.

Baroness Tonge: Will the Minister clarify the phrase "clinical commissioning group area"? I thought that it was not going to be defined. I obviously got the wrong end of the stick. GPs are free to have patients on their lists from wherever; therefore, what does he mean by their "area"?

Earl Howe: My Lords, I will address that question in a moment, if I may. The noble Lord, Lord Warner, asked how clinical commissioning groups will deal with the non-registered population in practice. Individual clinical commissioning groups will have responsibility for ensuring that patients resident in their area who are not registered with a GP have the same access to the care for which the clinical commissioning group has commissioning responsibility as a patient registered with a GP. Individual clinical commissioning groups will need to ensure that they have sufficient geographical focus to be able to commission emergency care services for anyone who needs them when in their area. The National Health Service Commissioning Board will be responsible for establishing a comprehensive system of clinical commissioning groups covering the whole of England, and the board will be responsible for commissioning primary medical care for the unregistered patient population. I think that my noble friend Lady Tonge is confusing two issues.

Lord Warner: Can I just be absolutely clear that I have understood the noble Earl? Is he saying that a clinical commissioning group with a defined geographical area for which it is responsible also has a responsibility to find out about the needs of all those who are not registered with a GP, including homeless people, asylum seekers, rough sleepers and you name it? Is he saying that the group has a responsibility to find out how many of those people are in its area and that it must commission services for them?

Earl Howe: Let me be clear: each clinical commissioning group will have a specific geographic area and will have responsibilities linked to it. This addresses the question asked by the noble Lord, Lord Rea, as well. Unregistered patients of any shape or kind are one example. Clinical commissioning groups will be informed by the work done in the health and well-being boards, whose job it will be to define the health needs of an area and what they believe the priorities are for commissioning in that area, and to produce a joint health and well-being strategy that addresses those priorities. The interaction between the health and well-being board and the clinical commissioning group should ensure that the marginalised groups of people to whom the noble Lord refers will be catered for.

Lord Walton of Detchant: The noble Earl has been extraordinarily helpful in his comments. However, in new Section 1A, entitled Duty as to improvement in quality of services, subsection (1) states:
	"securing continuous improvement in the quality of services provided to individuals for or in connection with ... the prevention, diagnosis or treatment of illness, or ... the protection or improvement of public health".
	However, it reads as if (a) and (b) were qualifying clauses, qualifying the services provided to individuals. As I read it, it does not make it clear that the quality of services provided to communities would be embraced by this even though it refers to public health. That is my concern, and I would be grateful if the noble Earl could in due course consult as to whether I am totally mistaken in that view.

Earl Howe: I will cover that point in a second. I should perhaps clarify that the area covered by an individual clinical commissioning group will be agreed with the NHS Commissioning Board and, as I will explain in a minute, that area should not without good reason cross local authority boundaries. That is a different issue from the issue raised by the noble Lord, Lord Rea, of GP practice boundaries, and we need to distinguish the two in our minds.
	The right reverend Prelate asked why we could not remove the words "provided to individuals". The duty on the Secretary of State to act,
	"with a view to securing continuous improvement in the quality of services"
	is worded to refer to the "services provided to individuals". This is because the NHS treats patients on an individual basis. Overall improvement in the quality of the treatment service will improve the health of the population as a whole, but we must not forget that there is a separate, complementary duty to improve the health of the population as a whole using public health mechanisms. Improvement is necessary in both prevention and treatment, and the Bill sets out separate duties in relation to other population-based activity; for example, population-based public health research.
	In answer to the noble Baroness, Lady Finlay, the Government accepted the NHS Future Forum's recommendation that the boundaries of local clinical commissioning groups should not normally cross those of local authorities, and this is now reflected in the proposed authorisation framework for CCGs, subject to the agreement of the process with the NHS Commissioning Board. However, we do not believe it would be in patients' interests to make this an absolute rule. One of the key roles for clinical commissioning groups will be to manage relationships with local hospital providers and in some areas patient flows into acute hospitals do not match local authority boundaries. The proposed authorisation framework makes clear that CCG areas may only cross local authority boundaries where, for reasons like these, it is demonstrably in the interests of patients.
	In answer to my noble friend Lady Cumberlege, whose comments I very much welcomed, all relevant clinical commissioning groups will be required to appoint a representative to the health and well-being board if part or all of their area falls within or coincides with the local authority area. That will provide a vehicle for NHS and local authority commissioners to work together on the health and well-being of the population. There is nothing to prevent health and well-being boards from inviting other clinical commissioning groups that have large numbers of registered patients within the local authority area to attend and be represented. I hope that goes some way towards addressing the concerns that the noble Baroness raised. She expressed a general fear about lack of coterminosity between local authorities and CCGs, leading to fragmentation. As I have said, there is going to be a presumption against CCGs crossing local authority boundaries, but there is an important point in this connection in Clause 20, which will impose a duty on the board in new Section 13M in relation to promoting integration; in particular, new Section 13M(3) will impose a duty on the board to,
	"encourage clinical commissioning groups to enter into arrangements with local authorities"
	where this would assist with integration of health and social care.
	The noble Baroness also referred to GP practice boundaries. She will know that the previous Government, as well as the present Government, were keen to ask patients about the choice of GP practice. It is our aim, which we expressed in the White Paper, to give every patient a clear right to register with any GP practice they want from an open list without being restricted by where they live. Many, if not most, patients are quite content with their local GP practice, but a significant minority have problems registering with a GP practice of their choice or with securing access to the high quality and range of care services that they deserve.
	I can inform the Committee that agreement was reached with the BMA today. NHS employers have been discussing our proposals with the General Practitioners Committee of the BMA as part of the annual GP contract negotiations, and the agreement that we have reached with that committee is that from April 2012 GP practices will agree with their primary care trust an outer practice boundary whereby they will retain, where clinically appropriate, existing patients who have moved house in the outer boundary area.
	There will also be a choice pilot in two or three cities, or possibly parts of cities, whereby patients will be able to visit a practice either as a non-registered out of area patient, for which the practice will receive a fee, or as a registered out of area patient. Practices will join the pilot on a voluntary basis. I think that that represents a very satisfactory way forward. We can look at which model works, if either of them does, and see what the problems are with each.
	The noble Baroness asked about the risk of cherry picking patients. We do not see that as a danger. Under their contracts, GPs have a measure of discretion in accepting applications to join their patient lists. However, they can refuse to register a patient only on reasonable and non-discriminatory grounds. They cannot turn patients away simply on the grounds of their medical condition, or for that matter on the grounds of their race, gender, social class, age, religion, sexual orientation, appearance or disability. In future, we want to make it easier for people to choose the best GP practice for themselves and their families. The pilot arrangements that we have agreed will be invaluable to understanding more fully the issues of GP choice.
	I hope I have covered most of the points that have been raised. I hope that my answer to the question posed by the noble Lord, Lord Warner, satisfied him, but I just reiterate that CCGs' responsibility for planning for homeless people and all the groups that he mentioned is a core part of the CCGs' functions.

Lord Newton of Braintree: My Lords, I take it that the answer to my question is that CCGs do have a duty to plan for everyone in their area. However, along the way, the Minister indicated that some of the information that will enable them to do this will come from health and well-being boards and their assessment of the needs of the population. The fact is that the health and well-being boards do not cover the same areas. They might cover the area of a number of CCGs, but they do not relate to the specific area of any specific CCG. The question is therefore: do the health and well-being boards have a duty to translate their information into the areas covered by CCGs?

Earl Howe: I am grateful to my noble friend. The point I was seeking to make was that health and well-being boards will be in a very good position to assess and have a sense of the unregistered and, if I can express it this way, the more dispossessed elements of society. I think CCGs will find that an invaluable source of information in planning the commissioning of services.
	My noble friend asked me a yes or no question: are CCGs just like PCTs? In terms of population responsibility, the responsibilities are very similar. CCGs are responsible for patients on the registered lists of their constituent practices as well as having specific area-based responsibilities, as I pointed out, linked to their unique geographic coverage. It is possible for individuals within that area to be registered with a GP practice which is a member of a different CCG. It would therefore be the responsibility of that other CCG. So that is a slight complication. However, it is important to remember the critical role of health and well-being boards in planning in a holistic way across an area covering not just the NHS but public health, social care and other services.

Lord Newton of Braintree: I am sorry to press the Minister further. I want to ask one further question and then I will shut up-I promise. Health and well-being boards, and possibly CCGs, will cover widely differing kinds of area: urban populations where there may be many more homes and people, asylum seekers and the like; conurbations of one kind or another; and a rural periphery. Let us make this oversimple. Do the CCGs in the conurbations know what their situation is in respect of homelessness, asylum seekers and all the other things that the noble Lord, Lord Warner, talked about?

Earl Howe: My Lords, there are perhaps several issues bound up in my noble friend's question. It is entirely possible that a CCG will cover two local authority areas. In that event, it will have a clear duty to work in partnership with both local authorities to improve health and well-being and to secure more integrated services. Do health and well-being boards need to translate their assessments for each clinical commissioning group area? The CCG will need to use the joint strategy of the health and well-being board to inform its commissioning plan according to the needs of its local population. It is in its interests to ensure that the information is translatable.
	I would be happy to write to my noble friend because there is a clear narrative here, although I may not be expressing it entirely clearly. Obviously, there will be instances where boundaries do not coincide. As I have said, we are aiming for that not to happen but it will in some cases and it has to be dealt with in terms of the duties that we set out.

Lord Warner: I will not torture or tweak the Minister any further but I will ask him to make a sensible response on this issue after today's Committee sitting. It would be extremely helpful if he could take two or three areas-perhaps an urban area and an urban/rural area-and show us where there is a health and well-being board and where there are pathfinder groups of CCGs, and how this would work in practice. I think that we would find this much easier to understand if there was a diagram.

Earl Howe: I absolutely agree with the noble Lord. It is all very well me trying to describe in words what the duties will lead to but a graphic depiction of how this might work is a very good idea, which I would be happy to follow through.

Baroness Tonge: I am sorry to torture the Minister further. He seems to be saying that clinical commissioning groups are PCTs by another name, with the exception of public health services and community services. That is the impression I get. Can he tell us how much it will cost to transfer the bureaucracy of the PCTs to the bureaucracy of the clinical commissioning groups?

Earl Howe: There is a hypothesis in my noble friend's question that I do not necessarily accept but I would be happy to write to her with the figures.

Baroness Hussein-Ece: I am sorry to press the Minister on the point I made about homeless families who are placed in different boroughs or areas by their local authority. Under the present system, the GP practice where the family was originally based would wash its hands of that family and say, "You are no longer in my area". Is the Minister saying that wherever a family has been placed, it would still be able to retain the services of the GP where it originated from or would they have to register with a practice close to the temporary accommodation in which they may have been placed. Such placements can last for many years. Will the family have to seek a GP close to where they have been placed or could they still use the GP services from whence they came?

Earl Howe: It would depend how far the family had moved away from the GP practice. What I was trying to say was that the agreement we have reached with the BMA comprises two elements. One is that the outer boundary of a GP practice is going to be flexed in a sensible and pragmatic way so that if you move a few streets away from where you were previously living, you can still be treated in the same GP practice. The other element of the agreement is the pilots that we are looking at. They are only pilots and we will set them up in order to experiment and learn lessons from how they work. It is impossible for me to give my noble friend a generalised statement at the moment because it will depend on the circumstances. At present, the rules will remain roughly as they are other than the flexed boundary rule that I have mentioned.

Baroness Finlay of Llandaff: My Lords, I thank the Minister most sincerely. Apart from anything else, he has explained the BMA agreement far better than I did in my attempted few sentences. I hope that that has provided some reassurance to the House.
	I am grateful to him for explaining the problem with the wording in Amendments 10B and 11A, and I accept that he has assured us of the totality of the Secretary of State's duties overall in relation to the two proposed subsections. I thank him for explaining, in relation to the other amendment in this group, that the mandate set by the Secretary of State is one to which the Commissioning Board must have regard. That was precisely why I was concerned about also having "areas" because the Commissioning Board will be contracting with GPs themselves for their clinical services, which is separate from the role of the clinical commissioning group. So I have a little nagging doubt and that is why I put this right at the front of the Bill. I am sure we are going to return to the word "area" as we work our way through the Bill.
	For the moment, however, I am grateful for the noble Earl's explanations. I also thank all noble Lords who have contributed to the debate, particularly the noble Lord, Lord Warner, for what I think was a flash of brightness in the fog when he asked for a diagram that will set this out geographically for us. That will be most helpful.

Baroness Thornton: My Lords, this has been a very worthwhile discussion. As I said at the outset, there are two issues here. I am grateful to the noble Earl for reassuring us about the issues to do with quality, which he has done very satisfactorily indeed. I should give the noble Baroness, Lady Finlay, a vote of thanks. I knew that she would explain the issues about area-based clinical commissioning groups much more clearly than I. Moreover, the noble Lord, Lord Newton, put his finger on it when he asked whether the clinical commissioning groups will be structured on the basis of clearly defined geographical areas contiguous with each other and inclusive of the entire population. I think the noble Earl said "yes" to that question.
	I am less happy about something that I think we will return to, which is how people who already fall through the gaps in care and access to primary care will be treated and whether their situation will be worse. That is because right from the outset I said that what we had to do was apply what is in this Bill to patients and conditions to see how it works for them. In Kingston at the moment, for example, a GP practice has been able to deregister 48 people with mental illnesses who live in a home. They have been scattered among GPs throughout the area. I think that that is very unsatisfactory and there does not seem to be any way of challenging the decision. It worries me that if we are establishing clinical commissioning groups that will have even more independence to take those kinds of decisions, things will get worse for those who need primary care rather than better.
	I will not press any of the amendments tabled in my name, but we will return to this issue. I beg leave to withdraw the amendment.
	Amendment 9 withdrawn.
	Amendments 10 to 11A not moved.
	Amendment 11
	 Moved by Baroness Hollins
	11: Clause 2, page 2, line 15, after "of" insert "physical and mental"

Baroness Hollins: My Lords, in moving this amendment I shall speak also to Amendments 105 and 180. I am pleased that they are supported by my noble friends Lord Patel and Lord Alderdice, and the noble Lord, Lord Patel of Bradford. The amendments concern the duty of the Secretary of State set out in Clause 2, in Clause 20 in respect of the National Health Service Commissioning Board, and in Clause 23 in respect of the responsibility of clinical commissioning groups. I speak as a psychiatrist and as a former president of the Royal College of Psychiatrists.
	It is time for a paradigm shift in the way we think about the health of the people of this country. When the word "illness" is mentioned, I suspect that in most people's minds there are images of physical illnesses such as heart disease, stroke, kidney failure and so on. The current wording in the Bill places a duty on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to promote comprehensive services in respect of both the physical and the mental health of the people of England. The Bill makes no specific mention of mental illness in respect of their duty as regards the improvement of the quality of services. I suggest that the word "illness" should be changed to "physical and mental illness" so that there can be no question about the Government's commitment to ensure parity between services for physical illness and services for mental illness. The amendments would also be in keeping with the Government's mental health strategy, No Health Without Mental Health, which states:
	"We are clear that we expect parity of esteem between mental and physical health services".
	Noble Lords might think that there are some pros and cons to these amendments. I have discussed their purposes with mental health charities, service users, practising psychiatrists and other noble Lords. I believe that the pros strongly outweigh any possible cons, but I will deal with the suggested cons first. It has been suggested that there is no need to emphasise that illness encompasses both mental and physical aspects because of course it does; it is so obvious that emphasis is unnecessary. But the stigma associated with mental illness is still such that, on the whole, people do not self-disclose when they have a mental illness in the same way that they might talk about diabetes or cancer. I am sure that noble Lords can remember a time when cancer was a taboo subject, largely because of fear and ignorance. Unfortunately, a lot of the manifestations of mental health problems still evoke fear in the minds of the public. Until we start to name mental health and mental illness much more explicitly, I believe that we will allow mental illness to remain something which is not discussed in polite company, something that is kept out of sight and out of mind in spite of the fact that in each of our lifetimes, one in four of us will have mental health problems. Probably everyone in this House has someone in their family or among their friends or colleagues who is experiencing the symptoms of mental illness at this time.
	It is not the same as including children or older people in the definition; nor to including a discrete group of conditions. Mental illness is relevant to every age and social group in the community. We all of us experience either good or less good mental health, just as we all experience good or less good physical health. Our physical health varies according to the presence of specific disorders, as does our mental health, and this applies just as much to children as it does to adults. Imagine a child with a complex neurological disorder who also has a mental illness. The child needs to be treated as a whole person with co-ordinated care by people who understand that the child's mental and physical illnesses have equal priority.
	The second possible con is that in labelling mental health in this way, specifically mentioning mental and physical illness, we might exacerbate the split between the two. Perhaps in 100 years' time we will have adopted a sufficiently sophisticated understanding of health that defining health and illness as being about both physical and mental aspects will no longer be necessary. However, at this point in time, clarity is more important than any disadvantage that may come from naming both.
	Another comment has been that mental illness is simply just another condition, similar to diabetes or stroke, perhaps, but this is not a 21st century way of thinking about mental illness and mental health. The Government very helpfully earlier this year published their mental health strategy and called it No Health Without Mental Health. That is the point of these amendments: there is no health without mental health and there is no public health without mental health.
	Given the scale of the changes the Bill introduces, the financial climate within which they will be implemented and the current underfunding of mental health services and care, I am keen to ensure that the Bill enshrines such a principle in law so that commissioning bodies can be under no illusion that they have an equal responsibility to commission high-quality and continuously improving mental health services as they have for services for physical illnesses. It would be extremely regrettable if the importance of mental health commissioning was overlooked because adequate reference to the parity that mental illness should enjoy with physical illness was omitted from the text of the Bill.
	Mental health is part of the continuum of health, both for individuals and populations, and it cannot be thought about as if it was a discrete disorder or set of disorders. Medical science today is demonstrating what it should have taught us many generations ago: that physical and mental illnesses are inextricably linked. Do not misunderstand me: I am not suggesting that mental health problems are all down to biology and genetics; environment and relationships play an enormous part in supporting our mental health. This point was made very well on the "Today" programme yesterday, when a service user, a patient who had lived with schizophrenia, spoke about his experience of his illness. Professor Robin Murray from the Institute of Psychiatry, spoke about genetic imaging and other research into schizophrenia which so clearly shows that it is a brain illness, albeit strongly influenced by social and environmental factors.
	The mind/body split has unhelpfully been set in concrete within the NHS, which uses different NHS trusts to treat mental and physical illnesses. This unfortunately fails to recognise the fact that depression, for example, is a very common co-morbid condition associated with diabetes, stroke and heart disease. It is not surprising, really, given that the brain is just one organ among many.
	Mental illness in someone with a recognised physical illness is often overlooked, delaying that person's physical recovery. As noble Lords will be aware, people who have severe mental illnesses are at an increased risk from a range of physical illnesses, as well as greater levels of obesity, and they have a shorter life expectancy. This is in part because, just as mental illness in those with physical illness is overlooked, so is physical illness overlooked in people with mental illness. We need to do more in all health services, including public health, to ensure that the connections between mental and physical illnesses are better understood; that service responses are co-ordinated; and that diagnostic overshadowing of one by the other is avoided.
	We also need to recognise the part that education, training and research will play in achieving parity of esteem for mental and physical illness. Many factors contribute to the poor physical health of people with mental illness and, for many people with severe mental illness, social stigma, poverty, limited housing options and reduced social networks contribute to the problem, as do difficulties in accessing physical healthcare. I hope noble Lords will support me in inviting the Minister to agree to these small but significant additions to the Bill about which I feel so strongly. I beg to move.

Lord Patel: My Lords, my name is on the amendment and I am pleased to support it. Before I say what I wish to say, I declare an interest as an honorary fellow of the Royal College of Psychiatrists, an honour bestowed on me by the noble Baroness, Lady Hollins, when she was the president of that college, having been introduced in glowing terms to her by the noble Lord, Lord Alderdice-exaggerated glowing terms, I may add.
	Noble Lords may wonder why I received that honour-and so do I-but I remember that at the time I was for several years chairman of the Clinical Standards Board for Scotland. It was during that time that I recognised that the provision of services for mental health was quite appalling compared to the services for physical health. It was through writing of standards for illnesses such as schizophrenia, to which the noble Baroness referred, that I discovered how appalling the situation was, not only in the environment where the care was delivered but in the care itself, and how that led not only to limitations in care but to limitations in resources for research and other end-producing standards.
	It was of interest to read:
	"Everything in my portfolio straddles the interface between health and care-mental health, social care, long-term conditions, cancer. Take for example mental health. The interdependencies between good mental health and good physical health are clear. Mental health sits at the point where health, social care and public health intersect. Delivering better outcomes in physical health will require mental health to be given parity of esteem. So that both mental and physical health problems get equal recognition in the commissioning and delivery of health and social care".
	These are not my words but the words of Mr Paul Burstow, the Minister of State for Health.
	"Parity of esteem" is not defined in the document. However, it would be reasonable to expect that this would mean recognition of the equal importance of mental and physical health. Perhaps the Minister will help us with a definition so that we clearly understand what is meant by parity of esteem. You would expect this recognition to be evident in terms of access to mental health services; funding for services proportionate to the disease burden; and mental health being equally at the forefront of the minds of the new clinical commissioning groups and structures.
	Sadly, however, this is not the case. For example, for a young person with a physical health problem such as diabetes, to which the noble Baroness referred, who is nearing an age where he is about to start receiving his care in an adult service setting, none of us would expect there to be any problem or difficulty with this move. However, consider a young person with a mental health problem about to make the transition to adult mental health services. Recent research indicates that as many as a third of all the young people who arguably needed continuing care did not make this transition. These young people fall into a gap that would not be acceptable in physical health care. Furthermore, even where a service is available, only 5 per cent of young people experience an ideal transition.
	Next, consider the disease burden that is attributable to mental illness. Mental illness is a cause of suffering, economic loss and social problems. It accounts for over 15 per cent of the disease burden in developed countries-more than that caused by all cancers. In the UK, at least 16.5 million people experience mental illness. Despite this burden, a proportionate allocation of funding to mental health services often does not reflect that personal and economic scale. Nationally, some 12 per cent of the total NHS budget is allocated to mental health. While it is difficult to call for increased expenditure in the current economic climate, there is clearly a need.
	There are clear benefits from mental health being regarded as the same as physical health. For example, poor mental health is associated with the increase of diseases such as cardiovascular disease, cancer and diabetes, while good mental health is known to be a protective factor. Poor physical health also increases the risk of people developing mental health problems.
	The amendments are therefore appropriate. They will ensure that the Bill enshrines the principle of equality of physical and mental health in law so that commissioning bodies know their responsibility to commission high-quality and continuously improving mental health services, as they do for physical health. That commissioning bodies have such a responsibility can in no way be assumed from the present wording of the Bill. While it places a duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to promote comprehensive health services in respect of both the physical and mental health of the people of England, the Bill makes no specific mention of mental illness with respect to their duty to the improvement in quality of services. It refers simply to the prevention, diagnosis or treatment of illness. I support these amendments and hope that other noble Lords will do the same.

Lord Patel of Bradford: My Lords, in speaking in support of these amendments I declare that I was formerly the chair of the Mental Health Act Commission. I have a long-standing interest in working to promote better mental health and in particular how we can best improve quality and outcomes in services. I echo what the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel, have said and shall try to put a little bit more flesh on the bones.
	It is clear to me from my work over the years in this area that we cannot and should not try to separate physical and mental illness. The separation of mind and body has been the focus of philosophical debate for many years but it is obvious to anyone who has at some time been unwell that physical problems have a profound impact on our mental well-being and that being unwell from a mental illness has profound impacts on our physical well-being. To quote the great American author and thinker, Henry David Thoreau:
	"Good for the body is the work of the body, good for the soul the work of the soul, and good for either the work of the other".
	I could cite a great many examples that demonstrate that truth. As the noble Lord, Lord Patel, said, compared with the general population, people with depression are twice as likely to develop type 2 diabetes, three times more likely to have a stroke and five times more likely to have a myocardial infarction. Approximately 10 per cent of people have serious depression, but this rises among those with cerebrovascular disease, where rates of major depression are twofold. Among those with diabetes or cancer it rises to threefold, and among those with recurrent epilepsy it can be as high as a fivefold increase. In fact, living with a physical illness can adversely affect our relationships, causing isolation and anxiety, which can be just as debilitating as the physical illness itself.
	Apart from the obvious common sense of these amendments, I am keen to see them passed because there is a need to bring these issues to the fore. Mental illness has for far too long been perceived as a Cinderella service lacking the serious attention it needs as part of a fully integrated health service. By creating parity between these twin aspects of our well-being and health, we can ensure that the improvements in quality that we all want to see are realised that much more effectively. In fact, I would go as far as to say that this is one of the single most effective things we could do to bring about these improvements.
	By emphasising parity in health and mental illness for the Secretary of State, the clinical commissioning groups and the NHS Commissioning Board, we will see some very tangible benefits. For example, we could see a broadening of the Government's health inequality agenda so that their indicators of disadvantage include mental illness and learning disability. The Royal College of Psychiatrists and the Disability Rights Commission have called for that. That would also help ensure that clinical commissioning groups seek improvements in health through the inclusion of mental illness in the annual health checks undertaken by GPs.
	The implications for improvement in commissioning are profound and speak directly to the stated aims of the Bill: that is, continuous improvements in health and in the quality of services. While it is correct that the Bill calls on the NHS Commissioning Board and clinical commissioning groups to promote a comprehensive health service with,
	"respect to both physical and mental health",
	there is still a need to be absolutely clear about the need for parity of esteem in physical and mental illness. This is not clear from the Bill as it stands. As the noble Lord, Lord Patel, said, it simply refers to,
	"prevention, diagnosis or treatment of illness".
	That is likely to perpetuate the current imbalances which exist with respect to mental illness services and needs. For example, we currently spend approximately 12 per cent of health and social care expenditure on mental health services. The actual burden of disease is as high as 20 per cent when taking account of all disability adjusted life years. Bear in mind also that there will be only one secondary care specialist on the clinical commissioning group boards, who in all probability will be a representative from the physical health services. This amendment does not mean that there should also be a representative from mental health services but it will ensure that the clinical commissioning group is absolutely clear that it must commission equally high quality and continuously improving mental health services.
	By ending the unhelpful dualism between mental and physical health that has so characterised our services, we will see a holistic approach to health and healthcare. At the same time we will start to end the stigma that so many people have lived with and that has been the cause of so much misery and lost opportunities to help people be well. I am sure all noble Lords will agree that the stigma attached to mental illness has caused service users and their families a great deal of harm. I am pleased to say that public attitudes to this have been changing. In the 2011 Attitudes to Mental Illness survey, the percentage of people agreeing that,
	"mental illness is an illness like any other".
	increased from 71 per cent in 1994 to 77 per cent this year. We should continue to support this positive trend in attitudes by emphasising the parity across mental and physical illness as these amendments seek to do.
	The statistics show that this is not just a technical or even a semantic issue. The potential benefits are profound. In the same attitude survey, we learn that only 50 per cent of people would feel comfortable talking to their employer about mental illness and nearly a third said they would not be comfortable talking to a close family member or friend. The trends are moving in a positive direction compared to previous years but I am sure noble Lords will agree that we still need to do a great deal more to ensure that people are able to access help quickly and appropriately. Parity between physical and mental illness is one way in which we can strengthen that process.
	I know that the Minister is a great supporter of issues related to mental health. I hope that he will support these vital amendments.

Lord Alderdice: My Lords, I am grateful to the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel of Bradford, for bringing these amendments forward. I have been happy to put my name to them-and I thank the noble Baroness, Lady Finlay of Llandaff, who very graciously withdrew her name in order that I could show my support for the amendments.
	Like the noble Baroness, Lady Hollins, I am a fellow of the Royal College of Psychiatrists, albeit I am a recently retired psychiatrist. I would like to support these amendments, but coming from a slightly different perspective from some other noble Lords. When I came into psychiatry many moons ago, we learnt that some 50 per cent of all hospital beds in my part of the United Kingdom were mental hospital beds. That is no longer the case, because there has been a great move towards community care-or at least having people with mental illness in the community, which is not always the same thing. It has many advantages, but one disadvantage is that people have lost a sense of the size and severity of the problem. They tend to think of mental illness as a bit like cancer or diabetes, or something of that kind-as another disorder, along with all the rest. But it is not; it is something quite different.
	Whenever any of us suffers from a physical illness, it feels like something that has happened to us that we have to respond and react to. But when something happens by way of a mental illness, what is attacked is our very selves, because having mentation is what it is to be a sentient, conscious, reflective human being. I am not talking about people feeling a bit down or depressed or reacting to circumstances or difficulties; I am talking about mental illness. Those differences have sometimes been misunderstood and forgotten, including by psychiatrists in recent years. What disappears, what is attacked and what is under pressure is the very thing that makes you a human being.
	One case in which that is most commonly seen is dementia. When my grandfather died and I was consoling my mother, she said, "John, my father died two or three years ago. It was only the shell that passed away yesterday". In truth, the person is gone. That does not mean that we do not care for the rest, but the person has gone. Whether it is an organic disorder, or an organic-related disorder like dementia, or a psychotic disorder such as progressive schizophrenia, or even a neurotic disorder such as obsessive compulsive disorders and anxiety states, it attacks what it is to be a human being. It is a very different thing. All sorts of aspects of the being are attacked-the volition, the will, the capacity to want to do things, disappears. The capacity to care for the rest of the self is often attacked. This means that the very kind of service that you have to provide for people with serious mental illnesses is quite different. Whereas it might be legitimate to say of many physical illnesses that we expect the person to come along and to understand that they have to make a bit of an effort, with someone who has a serious mental illness, whose very capacity to understand and to care for themselves and address those kinds of things, they are attacked by the illness itself, and that expectation must be modified and be quite a different thing.
	That leads me to be very supportive of the notion in the noble Baroness's amendment, which I share with her, that in the health service we need to understand the differences as well as the similarities and crossovers between mental and physical illness. Noble Lords have said that they have some optimism that the stigma is less of an issue now than it used to be, and they hope that we might get to a point where it will disappear. I am somewhat of a sceptic about that, because I think that there is something fundamentally different about having a physical illness, when you can feel the lump or the bump and reassure yourself, and mental illness, when frankly at times all of us have some uncertainty about our own stability in that regard-and with good reason. It provokes a very understandable anxiety about the very existence of the self, which means that there will always be a degree of fear about it that does not necessarily exist in physical disorders. I am always encouraged when people become more understanding, of course, and I am always encouraged by opinion polls that say that that is the case, but I retain a little uncertainty that we are really there.
	When I was training I used to come over from Belfast to the Royal Free Hospital in London for supervision every month. Sometimes the consultant was not ready to see me, so I would sit down among the patients in the clinic. I remember when the consultant came out one day and said, "I've decided that you're really quite stable, John". I said, "I'm sorry, what do you mean-why on earth have you decided that?". He said, "You don't seem to have any anxiety about sitting among the patients in the psychiatric clinic". The truth is that many of us have those kinds of anxieties. It is a different thing.
	When it comes to service provision, there is a greater tendency to ignore, forget and set aside the need for the resources for people who are suffering with mental illnesses. One of my concerns, as we move into a time of increasing austerity-and I suspect that will be the case for quite a period of time-is that there will be a temptation to focus on those services where patients can be demanding, emphasise their needs and promote the requirements that they have. Those who suffer from mental illnesses will find themselves shying away and not necessarily having the provision for it. Therefore, to put on the face of the Bill that the responsibility is for people with mental illness and physical illness is an important preventive factor for the next number of years-we can easily judge them to be years-of financial and economic pressure.
	It is not just that kind of pressure that exists. Over the last number of years, I have noticed with many of my colleagues in psychiatry that there has been a tendency to slip back towards the provision of care for those who have psychotic illnesses or organic mental states and to try to forget about those with neurotic disorders who may sometimes be dismissed as the walking wounded. They are severe debilitating disorders that destroy lives and damage families and relationships, but many do not get the attention now that they should. Putting it on the face of the Bill would help to keep it in people's minds.
	We are not necessarily talking about disturbances of personality. It is a different kind of a matter. I hope that when the Minister comes to reply he will understand that this is not merely a question of the needs of a particular section of the community or a particular disorder or group of professionals. It is about a particular aspect of being a human being, which affects all of us, inside and outside this House, and is extremely important for our health service to recognise and have always brought to its recognition-whether through the Secretary of State, referred to through Amendment 11, or the National Health Service Commissioning Board, referred to through Amendment 106, or at the level of a clinical commissioning group, referred to through Amendment 180. The issue is not with the precise amendments but the precise problem, which I hope that my noble friend the Minister will be able to reassure us upon.

Baroness Whitaker: We have heard very powerful arguments from all sides of the House in support of these amendments, from deep and distinguished professional expertise, which in turn is backed by the professional institutions. I know the Minister will want to pay heed to that.
	I would like to offer a lay view. These amendments would redress a deep imbalance. The Minister may well say again, as he did in his letter to Peers who spoke at Second Reading, that the Government's good mental health strategy,
	"makes clear an expectation of parity of esteem between mental and physical health services".
	And so it does. But that is not the same as making it happen.
	The Minister may point out again,
	"in law, the term 'illness' covers all disorders, both physical and mental, so it is perfectly adequate for any Act of Parliament to refer succinctly to 'illness'".
	The trouble is that however enlightened the intentions in the strategy, and whatever parliamentary draftsmen may say, we live in a culture which has for centuries relegated mental illness to the realm of the weird, the unmeasurable and the stigmatised, as others have said. Even after the great advances of the last 150 years, neither the resources applied nor that general public understanding which supports political action is remotely adequate for a realistic approach.
	What I have seen is that bouts of mental illness severely erode the ability to cope with the problems that life throws up. They do not mean that the sufferer has to be treated like a being apart but they crucially impair the ability to earn a living. How many of those with chronic mental illness hold down a job? They can irreparably destroy relationships, which I heard a lot about when I was on the board of the Tavistock and Portman NHS Foundation Trust, and as a consequence of this combination the sufferer often loses their home. This is devastating; it is arguably more serious than many physical illnesses in its consequences.
	When I used to volunteer for Crisis at Christmas, probably over half the homeless people I met were mentally ill. Dedicated professional volunteers came and attended to their coughs and colds, their teeth and their toenails. They sewed their buttons on and gave the heroin addicts methadone but there was never even the most limited talking therapy. I have had colleagues who have kept their proneness to clinical depression secret, even when medication controlled it perfectly adequately, out of fear for the career consequences, and others whose alcoholism was treated as only a disciplinary matter-contrast that with diabetes or severe allergies. This damaging general culture can be changed only if there are enough professional resources to make an impact on it and if there is no excuse, by means of the words-or lack of them-in the statute, to treat mental illness less seriously than physical illness.
	How is it that, in answer to the Question which my noble friend Lady Thornton asked on 3 October, the Minister was able to say that the Churchill Medical Centre, a GP practice, deregistered 48 patients with dementia and mental disabilities,
	"due to the resources required to support those patients"?-[Official Report, 3/10/11; col. WA102.]
	Are patients deregistered because they have asthma or congestive heart disease? I think not. Osteoporosis units are funded-good-but local psychotherapy units, which so often have to deal with the residue left by more superficial, short-term and cheaper treatments, are not. Cognitive behaviour therapy, excellent for some purposes, is so widely offered exclusively that it tends to push out a range of other treatments. This does not happen in cardiology. Counselling is often the initial treatment of choice; cheap and with a lesser degree of qualification required.
	I heard recently of a single mother, abused and abandoned by her partner, a drug addict, who was not really managing to cope with bringing up small children. She would have had a few weeks of counselling in her GP's practice and medication, followed by brief interventions by clinical psychologists but, like many others, this did not shift either her depression or her behaviour. Her anxiety was too deeply entrenched for short-term counselling to make much difference or prevent her taking her negative feelings and distress out on her children. In fact, she was one of the lucky few. She had a small, local psychotherapy unit near her and she received huge support from her weekly meetings over a long period but that unit, the Camden psychotherapy unit, will shortly lose its funding.
	The trend for the full range of mental health treatments to be available only to the rich, or those who can wait a year or more, will be exacerbated if there is not parity of esteem between mental and physical illness. Noble Lords may not be aware that the treatment they or their family might expect is simply not available to more than a very few poor people. It must be emphasised again what is at risk when people's mental health is jeopardised. It is not only their happiness; it is their job, their relationships, their capacity to be effective parents, their resistance to drugs, alcohol and crime, and their home. It is of course also our economy, our well-being and our ease and peace of mind which are impaired. Explicit parity of esteem is essential to redress this cruel imbalance. These amendments serve that purpose. I urge the Minister to accept them.

Lord Ribeiro: My Lords, I am very pleased to-I am sorry; I know how difficult it is for my noble friend. Would he like to go ahead?

Lord Newton of Braintree: I am sorry but I am really quite slow in standing up, as noble Lords will observe.
	I do not want to take a huge amount of time. I am not a member of the Alderdice-Patel-Hollins club and I will therefore not attempt to go down their professional path. I am, however, for the moment at least, a member of another club in that I chair a mental health trust-the Suffolk Mental Health Partnership NHS Trust-so I have an interest to declare. I want to express my strong general support for the basic thrust of these amendments, whatever the wording: to emphasise, in the words of the Government's White Paper, "No health without mental health". We need to ensure that mental illness is treated with parity in these matters, so far as we can.
	I will make only another couple of observations. First, it is worth remembering that one of the notorious pressures on A&E departments at the moment is people turning up with mental illness problems, in effect, and needing the attention of mental illness specialists. This spills over and crosses the boundaries. I still think it right that there should be separate mental health trusts, but we need to recognise these linkages. Secondly, we need to recognise that this is an area in which integration with social services is particularly important. Integration is key because of the extent to which mental illness services are provided not in hospital but in the community and on a combined operation. As an aside which we will return to, the CQC needs to improve its act in terms of assessing community services for the mentally ill, which in my view it is not at present sufficiently equipped to do. That is a point we shall come back to. My main point is strong support for the principal thrust of these amendments, which I hope my noble friend will feel able to accede to.

Lord Williamson of Horton: My Lords, briefly but warmly, I support Amendment 11, which seems to me to be desirably explicit and logical in the structure of the opening clauses of the Bill. It is desirably explicit because, while I am sure that the Minister actually wants continuous improvement in the quality of service in connection with the prevention, diagnosis or treatment of physical and mental health, those words do not appear in Clause 2. There remains in the wider public some feeling that mental health has a lower priority than physical health. I believe that there has been a huge improvement in the priority given to mental health-I have a lot of experience of that because of my family circumstances-but the feeling I have referred to exists. Therefore, to be explicit on mental health in this clause is good.
	The amendment is logical in the Bill because under subsection (1) of the new clause in Clause 1:
	"The Secretary of State must continue",
	to promote,
	"a comprehensive health service designed to secure improvement ... in the physical and mental health of the people of England",
	yet we do not have that phrase in Clause 2, where we come on to,
	"improvement in the quality of services ... in connection with ... the prevention, diagnosis or treatment of illness".
	That directly contributes to what is expressed in Clause 1, so we need to carry over that phrase and avoid its omission in Clause 2. That is why I support this amendment.

Lord Ribeiro: My Lords, I will be brief on this. I strongly support the amendment because it is important to recognise that mental health and acute clinical health go hand in hand. Most hospitals throughout the country started with psychiatric services outwith the main hospital buildings. Over many years we have tried desperately to integrate the service. We no longer have the concept of the psychiatric Bedlam that was the case in the past.
	For the last five years or so of my clinical practice, a rotation of junior doctors came to work for me. They would spend four months on general medicine, four months on surgery and four months on psychiatry. As a consequence, I learnt quite a bit about psychiatry, although I am not sure that they learnt an awful lot about surgery. That was an example of integrated care. The importance of it is that a lot of the acute psychotic and suicidal admissions to hospital come through the accident and emergency department. They do not come through the separate door of a psychiatric unit at the other end of the hospital or in a different block. They come to the acute part of the hospital.
	I am not saying that the Bill team necessarily overlooked this but, as has been pointed out by the noble Lord, Lord Williamson, if proposed new subsection (1)(a) is to refer to the Secretary of State's duty to and responsibility for "physical and mental health", it stands to reason that, as is currently the case, the Secretary of State delegates responsibility for the provision of the health service to the strategic health authorities and PCTs. Their successor bodies will be the national Commissioning Board and the clinical commissioning groups, so it stands to reason that those two bodies must also have responsibility for mental and physical health. It is vital that the three major groups who have responsibility for the health service in this country-the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups-should all have a responsibility to deal with these two areas of healthcare, because they form part of an integrated service.

Lord Layard: My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed-he had been there for three weeks. At the end of our conversation about mental health, he said, "You know, I've just realised something. I've been in this job for three weeks, I've had about 50 meetings and this is the first time I've heard the words 'mental health'". That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.
	First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating that those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.
	However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said "normally". That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.
	Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners' priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.
	Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people-those suffering from angina, lung disease or a stroke, for example-suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.
	We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.
	Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase "physical and mental illness", and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the Secretary of State. I urge the noble Earl to take this amendment very seriously.

Baroness Murphy: My Lords, I rise briefly to support the eloquent speech by my noble friend Lady Hollins and other noble Lords who have spoken in this debate, if only to give the House a hat trick from the psychiatrists who are here today.
	In 1845 the Lunacy Act first separated physical and mental health with the building of the asylums. Before that, in the Poor Law Commission's provision of service to the general population, around 30 per cent of the medical time of general practitioners and specialists who were engaged by the Poor Law Commission was spent on people with mental health problems and what we would call learning disabilities. That division, however good it was in developing the services in other ways, has led to a separating out which continued after 1948, to the detriment of the development of services.
	This Government and their predecessor have done an enormous amount to right that imbalance. As I have pursued my career in psychiatry, I have seen a dramatic difference in the investment that has been made in mental health services. However, there is still a lack of parity and when people talk about illness they still mean physical illness. I do not know whether the wording "physical and mental" is quite right in this amendment. However, it seems to me that the time is right to have an explicit provision on the face of the Bill regarding the equal importance of mental health and physical health in building a healthy nation. Unless we address physical and mental health together, we will not improve public health. It would be a good time to get such a provision in this Bill as it moves forward with a new style of NHS. I hope the Minister agrees that this is too important a matter to let it go.

The Archbishop of York: My Lords, I speak as somebody who supports Mind and as somebody with a brother I followed who had acute mental illness and died from it two years ago. I have listened to noble Lords' speeches, and that of the noble Baroness who moved the amendment, on this amendment and the consequential Amendments 105 and 180. I agree with everything that they have said. It is important to highlight the fact that health and illness include both mental and physical aspects; to me that is not problematic. However, the question I want to ask is, do we still need to speak of them in almost separate categories? The noble Baroness, Lady Murphy, referred to my anxiety; namely, that because we have separated out mental and physical illness, would inserting the words "physical and mental" in relation to illness continue to exacerbate the problem? Is it necessary to put "physical and mental" in this part of the Bill, or will the noble Earl tell us where that matter can be spelt out elsewhere, not necessarily in the Bill?
	Noble Lords will probably say of my next point, "We would expect him to say that". I am one of those who believe that human beings are psychosomatic spiritual entities. The element of the spiritual well-being of people is not on the face of the Bill but I am absolutely convinced that, as it stands, my needs would be taken care of because it talks about,
	"the prevention, diagnosis or treatment of illness".
	Illness can be physical or mental but it can also be spiritual. I will not detain noble Lords long but when I first became a vicar of a parish in south London I was invited into a home because somebody said that there was a presence there. I did not understand that phrase but I went into the home where there was a young girl who had not been able to move for nearly three weeks. The GP, a psychiatrist and a psychologist had visited the house. Sometimes the girl shouted a lot in the middle of the night. I went into the house and asked how the girl had got into that difficult state. Somebody said that they had been to a witches' coven that night where a goat had been sacrificed and the young girl was absolutely petrified that she would be sacrificed next. She could not speak apart from shouting. Doctors, psychiatrists and psychologists had attended the girl. All that I could do was to say a prayer in that little house, anoint the girl with oil and light a candle. I left and received a telephone call later to say that the young girl was no longer terrified and had started to speak. That was not mental or physical illness; there was something in her spirit that needed to be set free.
	I am content that the Bill covers all those aspects of the human person simply by using the word "illness" and through establishing a well-being and health board, which suggests to me that that board has a responsibility to ensure that physical, mental and spiritual well-being are taken care of. After all, in our schools these days we emphasise not only the personal, but the physical, mental and spiritual dimensions of a person. Hospital chaplains will tell you that the work they do does not address purely a person's physical and mental aspects. I do not want to divide up a human person. Therefore, I believe that the Bill covers people's needs without inserting the words "physical and mental".

Lord Rooker: My Lords, on balance I agree with the most reverend Primate. I speak purely as a lay person but I am very happy to support the noble Baroness, Lady Hollins. I have no medical training. One almost has to declare that as an interest in this debate. However, mental illness can lead to physical illness and massive social exclusion.
	I want to share my experience with the House as it is as relevant today as it was at the time to which I refer. Back in 2003, the then Prime Minister and Deputy Prime Minister commissioned the Social Exclusion Unit to carry out work on how we could attack the cycle of deprivation associated with mental illness. The report was published in 2004 with a 27-point action plan. At that time it was a rule of procedure that a couple of Ministers who were not involved in the matter on a departmental basis chaired the steering group that oversaw the work. I was one of the two Ministers. The other was Rosie Winterton, who is now the Labour Chief Whip in the other place. We launched the report at the headquarters of BT. We did that simply because one of the BT occupational medical staff was on one of the relevant overarching boards, but BT's record as an employer in relation to the mental health of their employees was absolutely first class. Therefore, we were happy to use the BT headquarters for the launch.
	Two departments later, as I travelled round Whitehall departments, I wondered what had happened to the 27-point action plan. These things are developed but the Ministers and civil servants involved with them move on. The relevant civil servants were very surprised to hear from a Minister who had had such a tenuous connection with the work he was asking about. The noble Baroness opposite is aware of this as she was involved with the Social Exclusion Unit. The civil servants told me that the action plan was still in place. I have not familiarised myself with what has happened to it over the past couple of years and I would like to be given an update on it. I would like to share with noble Lords some of the points contained in the factsheet that the Social Exclusion Unit published as they relate to some of the myths that have been mentioned. We need to expose those myths and meet them head on.
	Four myths are exposed in the Social Exclusion Unit's factsheet. I will not detain noble Lords for long as this has been a fascinating debate. The first myth is:
	"People with mental health problems are dangerous and violent".
	However, the factsheet adds:
	"People with mental health problems are more likely to be the victims rather than the perpetrators of violence. Less than 5 per cent of people who kill a stranger have symptoms of mental illness".
	The second myth states:
	"Mental health problems are rare".
	We have heard that myth being busted in tonight's debate. Indeed, the factsheet states:
	"Common mental health problems affect up to one in six of the general population at any one time. Almost everyone will know someone who has had mental health problems at some point in their lives".
	The third myth states:
	"People with mental health problems are incapable of work".
	However, the factsheet states:
	"US research found that up to 58 per cent of adults with severe and enduring mental health problems are able to work with the right support".
	I will give an example of that in a moment.
	The fourth myth states:
	"People with mental health problems do not want to work".
	However, the factsheet states:
	"35 per cent of people with mental health problems who are economically inactive would like to work, compared to 28 per cent of those with other health conditions. Many successful people have had mental health problems".
	In fact, as part of the exercise, I went for a day and a half around London to look at projects manned exclusively by people with mental illnesses. One was at a restaurant, and the only person involved in the restaurant who did not have a mental health problem was the chef, who had come down from a Park Lane hotel to do the training. Everyone else in the kitchen and the front office had a mental health problem. In fact, nine months later, I took my private office staff for their Christmas lunch there. My visit had been in April and I said, "If I am still around at Christmas we will come here for our private office lunch". Indeed, we did that. When visiting the three projects, I was driven around by one of the patients. I have never felt as safe in a van as I have felt when driven by anyone else. I had no problem whatever. The idea that normal activity cannot take place or that you cannot be included socially is, of course, a myth.
	I want to share one of the other aspects that we put out in a factsheet on this issue. The factsheet states:
	"Nearly one-fifth of respondents to the Social Exclusion Unit's consultation argued that mental health services needed to become more socially focused"-
	and more holistic. The factsheet continued:
	"GPs issue sickness certificates when they assess that a person cannot perform their usual work. Mental health problems are more likely to be listed on the sickness certificates in the most deprived areas of the country".
	That is another fact that we must take on board.
	"It is important to ensure appropriate pathways of care between primary and secondary services; up to 28 per cent of referrals from primary care to specialist services are inappropriate".
	I will not read out all the facts, but shall quote the final two. It is stated:
	"The range of services is more limited in rural areas, with specialist services often absent".
	That is the reality of many services, but this is the one that we are dealing with. It continues:
	"In 2002, 87 per cent of rural households were 4km away from a GP surgery".
	My final example states:
	"A person with schizophrenia can expect, on average, to live for ten years less than someone without a mental health problem, mainly because of physical health problems".
	One therefore has to deal with: stigma and discrimination-and we have heard examples of that; the role of healthcare professionals, which we dealt with in the factsheets relating to employment, welfare and benefits; and the role of families and carers, in particular. I shall leave alone the criminal justice system and other issues. Putting the amendments in the Bill is simple-it does not cost anything in terms of money; it should not upset the parliamentary draftsmen; but it sends a massive signal to the whole structure of the National Health Service that Parliament has highlighted and identified this issue, which relates to both Houses. We do not want it to be put in a backwater. We do not want it to be the first thing that is cut. People have to be treated holistically, because we know that if their mental health problems are not treated properly, physical problems start and we then get the queues at accident and emergency-and other pressures on GPs.
	I am therefore very happy to support the amendments in the names of noble Lords from all around the House. The work of this Government, which I applaud, was mentioned, and I have provided examples of the work of the previous Government where we were trying to deal with the relationship between social exclusion and mental health. It went right across the board-every government department had a role in this. The issue should not be left just to the health department or the National Health Service. It must be dealt with properly by every department-the economic ones as well as the health ones.

Baroness Armstrong of Hill Top: My Lords, it is particularly apt that I follow the speech of my noble friend because, in supporting these amendments, I wanted to relate a little of my experience as the Social Exclusion Minister who came in and tried to learn from all the other things that we had done in government-and what we had missed and needed to come back to. One of the issues that we came back to that is particularly apposite to the amendments related to people who do not fit into any category, who are the most vulnerable and who turn up at different places to try to get a service. No service treats them as an individual who has several problems.
	Most of these people have mental and physical health problems and probably have an addiction. They are probably difficult to deal with and are likely to get aggressive because they know that they are not getting the response they need to help them move forward. We set up some pilot projects which I now work with as chair of the Cyrenians in the north-east-a charity which took up one of those pilots and extended it. The pilot is paid for now by Newcastle City Council and the PCT, which is much bigger than the subsequent clinical commissioning groups will be. I was not sure whether I should raise this matter in the previous group of amendments or in this one, but I do not want to keep having to rise to speak because there are issues here that the Government need to address. I chose these amendments because they relate to the Secretary of State, the national Commissioning Board, and the clinical commissioning groups.
	Some things will have to cross those boundaries and be paid attention to by more than just a clinical commissioning group on its own, because the people we are talking about do not remain in one place. Sometimes there are insufficient of them in one place for a clinical commissioning group to take account of what they are going to need. We have people who go round and find the most disadvantaged and the most dispossessed-the ones who are not fitting in anywhere. We use ex-clients to go and find them. Most of the money comes from the local authority.
	We persuaded the PCT to appoint a community matron with whom we work and to whom we send those people. She is then able to assess their physical and mental health needs. This has substantially reduced in-patient care, and because we have a different system we can show that fewer people end up in A&E and are then admitted to hospital. Such an arrangement can save money but is also able to provide interventions at an earlier stage-and that was what attracted me about the amendments, because they relate to prevention, diagnosis and treatment.
	However, we do not work just with the homeless; we also have three projects for addicts. One of them is a 12-step, 12-week day-centre programme. The programme is fairly tough and the addicts have to be abstinent. We pay for that with money from three PCTs which were so enthusiastic about the work and what it was producing that they are now funding another centre for addiction, where we take in on a residential basis mothers and their children to seek to prevent the children going into care-because that was what was happening. We still have a small problem with the acute providers because sometimes when a family was going to come to us the providers had increased the methadone rather than helped the mothers to come off the methadone. We use the recovery method rather than methadone.
	I hope that the Committee can see that these are complex cases, with complex interventions that are aimed at preventing more difficult interventions later.
	I cannot see one clinical commissioning group commissioning any of this work, because it will be too expensive and there will not be a sufficient body of people to justify the work and money that it would need to put in. That is why, in the new architecture, the Government need to think how they will respond to those more complex problems, where the voluntary sector is coming up with more innovative solutions, but they need also to deal properly with what is often called dual diagnosis-I think it is often triple and quadruple diagnosis-where people have more than one problem. We need to bring the different groupings together to make sure that the needs of that individual or that family are addressed in a holistic way. It is important to recognise that more than a physical illness is brought to the table, as it were, in those cases. At least the amendment acknowledges that both physical and mental illness must be addressed.
	We will get a complex architecture under the Bill, and it will be all too easy for people to fall back through the cracks within that architecture and for there not to be a holistic approach. The next set of amendments, which talk about integration, are also important, and I will come back to them, but the Government need to think again about how to address those complex issues in a way that allows the whole person in that patient to be addressed in a more effective way than we are often able to do at the moment.

Baroness Masham of Ilton: My Lords, I first want to ask a quick question to my noble friend Lady Hollins or the Minister. Would the words physical and mental include those people who have a drug and/or an alcohol problem? Would addiction come under "mental". I do not want those people to fall through the net, as was said by the previous speaker.

Lord Mackay of Clashfern: I just wanted to say a word or two about the drafting involved in this. The noble Lord, Lord Williamson, pointed out that the opening clause, which is the foundation of the health service, states:
	"The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement ... in the physical and mental health of the people of England, and
	(b) in the prevention, diagnosis and treatment of illness".
	That is precisely the phrase that is the subject of the amendment, but it comes earlier in the Bill. I cannot believe that when the people who put the health service together in 1946 used that phrase, they did not have in mind that physical and mental health involved the idea that if there was illness, it could be either physical or mental. If we are to change an exactly similar phrase later in the Bill, consideration needs to be given as to whether we should do it at the beginning which is, after all, in many ways the most important place.
	I have every sympathy with all that has been said, and I am sure that it is right that we take serious account of it. We must remember the point made by the noble Baroness, Lady Murphy, about the need for integration of treatment for mental illness along with physical illness. Anything that separates them might not be conducive to progress. I have every sympathy with the proposal.

Baroness Thornton: My Lords, I congratulate the noble Baroness, Lady Hollins, on bringing forward the amendments and all those who have spoken in what I think has been an extremely useful debate. All those months ago, we had all-Peers meetings about this and many other issues. I am sure that the quality and comprehensive nature of the amendments owes something not only to talent and expertise but also to the fact that the experts in the House have been working with many organisations over a long period. I congratulate everyone on the quality of the debate and the amendments.
	The amendments approach the Bill holistically-I do not really like that word. They concern the Secretary of State's responsibilities, the duties of the Commissioning Board and the duties of the clinical commissioning group-the triggers, the levers that may make this a reality. Because of that, I am very attracted to them. It is also important that they express the expectation of parity of esteem between mental and physical health services. As has been said, my Government and this Government have certainly made progress on this issue. I look forward to hearing the Minister's comments, and I hope that he will find some way to recognise the support for the amendments across the House.

Earl Howe: My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a debate of very high quality, covering a topic of huge importance. All the amendments deal with the same matter. Each seeks to amend the duty of quality to include an explicit reference to the prevention, diagnosis or treatment of physical and mental illness. Amendment 11 does so for the Secretary of State; Amendment 105 applies to the NHS Commissioning Board; and Amendment 180 applies to clinical commissioning groups.
	I completely share the noble Baroness's concern that we should never forget mental health in the drive for improving quality-quite the contrary. The noble Lord, Lord Patel of Bradford, and many others, mentioned parity of esteem between mental and physical health and the need to end the dualism in thinking that has in the past hindered an holistic approach to care. Noble Lords have expressed the concern that the Bill is wrongly silent in not referring explicitly to mental illness. I hope that I can successfully plead not guilty to that charge. First, I reassure all noble Lords on the central point of drafting, which is that all references to illness already include both mental and physical illness. The term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. As a result, references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words. The definition is already there. Therefore, the signal mentioned by the noble Lord, Lord Rooker, is already there.
	The new duties placed on the Secretary of State for Health, the NHS Commissioning Board and clinical commissioning groups continuously to improve quality as defined by the noble Lord, Lord Darzi, already apply to the provision of both physical and mental health services. That is not to say-and I would not seek to suggest-that such services need no improvement. The noble Lord, Lord Patel, was quite right to draw attention to variations in mental healthcare around the country, despite the significant additional resources that have been directed to mental health services in recent years.
	I fully agree that the National Health Service must look holistically at both the physical and mental needs of the patients whom it is there to serve. That is why the NHS outcomes framework, which we published last year, seeks to drive better health outcomes for those with mental illness. That is where the difference will lie in future. For example, Domain 1 of that framework, which focuses on preventing people from dying prematurely, includes a specific indicator on premature mortality in people with serious mental illness. Domain 2 of the framework focuses on enhancing the quality of life for people with long-term conditions, regardless of whether these are physical or mental health-related. However, to guard against the risk that there might be an overriding focus on physical health, there is also a specific indicator looking at the employment of people with mental illness. Clinical experts, including the Royal College of Psychiatrists, agree that this is an important outcome for people with mental illness and one that the NHS can make a significant contribution to improving. Finally, Domain 4 of the framework focuses on:
	"Ensuring that people have a positive experience of care",
	including a specific indicator to capture the experience of healthcare for people with mental illness.
	In addition to the NHS outcomes framework, there are a number of other policy initiatives, tools and levers to support the improvement of mental health outcomes. The noble Baroness, Lady Hollins, and my noble friend Lord Ribeiro very pertinently mentioned mental health comorbidities, and this is where the work of NICE will have a part to play. We have asked NICE to prepare quality standards on many mental health topics, including depression with chronic physical health problems. The full library of quality standards, which is expected to total around 175, will contain a further large range of mental health topics.
	The noble Baroness, Lady Hollins, and my noble friend Lord Newton referred to No Health Without Mental Health, which we published in February. This is a cross-government mental health outcomes strategy for people of all ages. It was co-produced with the mental health sector and public health and social services organisations. It is probably worth my briefly setting out the six overarching objectives in that strategy.
	First, more people of all ages and backgrounds will have better well-being and good mental health. Fewer people will develop mental health problems by starting well, developing well, working well, living well and ageing well. Secondly, more people who develop mental health problems will have a good quality of life, with a greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates, and a suitable and stable place to live.
	Thirdly, fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. Fourthly, care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives in the least restrictive environment, and it should ensure that people's human rights are protected.
	Fifthly, people receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service. Sixthly, and finally, public understanding of mental health will improve and, as a result, negative attitudes and behaviours towards people with mental health problems will decrease.
	I believe that those are the right aims but we were also quite clear in the strategy that we attach equal importance to mental and physical health, and that mental health services should have "parity of esteem" with physical health services. We have already made very useful progress in implementing the mental health strategy, and I suggest that this work on the ground is at least as important as having appropriate wording in the Bill.
	The noble Lord, Lord Patel, asked what the meaning of "parity of esteem" is taken to be by the Government. We mean that mental health should be a priority alongside equally pressing physical health problems. That is why the strategy is called No Health Without Mental Health and why we have included mental health in the NHS outcomes framework, as I have mentioned, and commissioned half a dozen NICE quality standards on mental health topics, with more on the way.
	The noble Lord, Lord Patel of Bradford, made the very good point that clinical commissioning groups will need good advice on mental health issues. We entirely agree but this will come in a variety of forms. The board and clinical commissioning groups will be required to obtain clinical advice from a broad range of professionals with expertise in the prevention, diagnosis or treatment of illness and in the protection or improvement of public health appropriate to enable them effectively to discharge all their functions. This would include, for example, obtaining advice when making commissioning decisions-for instance, for people with specialist mental health needs. There are powers in the Bill to enable the board to issue guidance to CCGs on the discharge of this function.
	As well as promoting effective clinical leadership and multi-professional collaboration around specific conditions and pathways, we expect doctors, nurses and other professionals to come together in clinical senates to give expert advice which we anticipate clinical commissioning groups will follow in practice on how to make patient care fit together seamlessly in each area of the country. Clinical senates would provide advice and support on a range of issues and from a variety of health and care perspectives, including those of mental health specialists and of professionals who sometimes go unheard, such as allied health professionals. Health and well-being boards, as we have already discussed, will provide an opportunity to join up health, social care and services that have an impact on health generally.
	The most reverend Prime the Archbishop of York asked where would be the right place in the Bill to show the importance of mental health, if not here. While it is important to remember the role of the Bill, it is equally important to bear in mind the role of non-legislative work. I have already referred to some of that. The Bill is designed to set out a framework in which high-quality care can be delivered. The Bill and its duties cover all services, making no distinction between mental health and physical health. The wider, non-legislative work offers broader opportunities to delve into the detail required-for example, the NICE quality standards, commissioning guidance and the outcomes framework-and that is the work that will make a real difference to improving the quality of services, fulfilling the duties set out in the Bill.
	The noble Lord, Lord Layard, referred in his customarily authoritative way to talking therapies. I completely agree with him that this is a very important issue. He will know that we have committed to invest more than £400 million over the next four years to expand access to psychological treatment-IAPT services-across England. We are building on the previous Government's excellent work in this area, which has seen more than 600,000 people with mild to moderate depression enter treatment. I pay tribute to the noble Lord for all his efforts to shine the spotlight on this important area.
	The noble Baroness, Lady Armstrong, challenged me to show how the new NHS would cope with those with multiple and complex needs, and she was right to do that. I completely agree that people need to come together to ensure that service planning is holistic. She is equally right to say that sometimes an individual clinical commissioning group might not have that capacity. However, here again the role of health and well-being boards will be critical, bringing people together, setting out a joint strategy and promoting joint working. I look forward to longer debates on this topic over the coming weeks.
	As I mentioned earlier, Section 275 of the National Health Service Act defines the term "illness" to include mental disorder within the meaning of the Mental Health Act. Where it appears in Section 1 and other provisions of the Act, it has always been referred to without those additional words. Instead, the term has always been defined to include mental and physical illness. Therefore, like the noble Baroness, Lady Murphy, and the most reverend Primate, I do not think that it would be desirable to make an express distinction between the two in the provisions of this Bill, particularly when we need the service to think holistically about both the physical and mental health needs of patients.
	With those comments, I hope that the noble Baroness, Lady Hollins, is more reassured and will feel able to withdraw her amendment.

Baroness Hollins: My Lords, I thank the noble Earl for his answer and indeed for the sustained interest and commitment that he has always shown to mental health services. I have been heartened by the enormous support across the House for my amendments and was impressed by the breadth of interest shown in mental illness.
	There is wide recognition of the need to try to bring mental illness more into view, particularly perhaps to make it more explicit in the Bill. The indicators of better outcomes, about which the Minister spoke, are indeed welcome. We have heard how much they are needed. I hear every day of how mental health services are being disproportionately cut. We are still a long way from the kind of holistic service that we would all like to see. That is the difficulty and why I still feel quite strongly that we need to name mental and physical health. This may not be the right place in the Bill to do it, but I still think that when they hear the word "illness", people think about physical illness. It may be defined but I do not think that it is what people hear. I have heard Ministers of Health and Secretaries of State speaking about health and illness over many years and nearly always when they do so we know that everybody is hearing "physical illness" and not hearing or thinking "mental illness". We know that mental illness includes addiction and a wide range of different disorders and conditions.
	I take note of what the noble and learned Lord, Lord Mackay of Clashfern, said and his question about where the amendment would best fit. I am willing to withdraw the amendment but I hope to hear more discussion and thought about how to show more explicitly in the Bill that there is a real intention in a 21st century Bill to have parity for mental and physical illness. In 100 years' time somebody could be standing here arguing to take away the words "mental illness" because they are no longer needed, but we are such a long way from being able to do that. I am not arguing that mental illness is just a medical condition-not at all. It is a condition, as the noble Lord, Lord Alderdice, reminded us, which affects the very essence of our being. It requires integrated services and integrated approaches; it requires medical attention. But it also requires an awareness of the social recovery models of support and help. I will bring back the amendment at the next stage. I beg leave to withdraw the amendment.
	Amendment 11 withdrawn.
	Amendment 11A not moved.
	House resumed. Committee to begin again not before 8.43 pm.

Big Society
	 — 
	Question for Short Debate

Lord Ponsonby of Shulbrede: To ask Her Majesty's Government what plans they have for developing the role of the magistracy in the Big Society.

Lord Ponsonby of Shulbrede: My Lords, noble Lords will be aware that this year is the 650th anniversary of the establishment of the magistracy. Iwas sworn in as a magistrate nearly six years ago and I now sit both on adult and youth matters. The lay magistracy is a triumph of volunteerism and localism. Even in central London where I sit, most of my colleagues have lifetimes of experience of living and working in London and bring this experience to their adjudications on a daily basis. Like jurors, magistrates are unpaid and unqualified; unlike jurors, however, we will hear hundreds of cases a year and we are trained and advised by experienced legal advisers who keep us on the legal straight and narrow. Some 95 per cent of criminal cases are dealt with in the magistrates' courts. I believe that all this adds up to a unique institution which is a cornerstone of civic life.
	So what of the future? In this short debate I want to concentrate on areas where I believe the magistracy could play a greater role in enhancing the public's faith in the justice system. There seem to be three main problems affecting the public perception of the court system. The first is the poor administration and slowness of the court system itself. The second is the public scepticism on the appropriateness of community-based sentences and the third is the representativeness of magistrates themselves. To tackle the first issue-the poor administration of the court system itself-when I first sat only six years ago I was amazed at the complete lack of computer support. The whole process in court was paper-based. Now it is common to book trials online, for lawyers and JPs to check sentencing guidelines online and also to call up maps and photos of locations for traffic matters, and things like that. Nevertheless the bulk of the process is still paper-based. I was heartened to note that in the new Westminster court house in Marylebone every desk position in every court has a plug and phone jack to enable a computer to be set up. Digitising the criminal justice system is a huge and complex task but progress is being made and the benefits are there to be reaped. I understand that 2014 is the target date for completing this task.
	However, court is a team effort and each member of the team needs to contribute to the effective management of the case load. Digitising the system will reap big benefits but will never replace a properly motivated and appreciated court team. The Government need to keep that at the forefront of their mind when introducing sweeping changes. It has to be a concern that cuts to staff will hold up progress towards digitising the courts process and reduce staff morale, which in turn will affect performance and the public view of the effectiveness of the system. Magistrates can help by setting the tone of the court itself-making sure it is well managed, making progress whenever possible and putting the interests of justice first without cutting corners or delaying decisions. I believe that magistrates can and do help the process by using courtrooms when appropriate and being sympathetic to other people using their computing systems.
	The next matter is public scepticism on the appropriateness and effectiveness of community sentences. I believe that this scepticism is exaggerated mainly by the press and that most people want community sentences to be used as much as possible. They also want them to be tough and effective. I read the speech made by the noble Lord, Lord McNally, to the University of Hertfordshire at the beginning of October and I agreed with his aspirations for community punishments. It is, however, in the role of magistrates that we see a lot of people who have reoffended while on community sentences but we do not see those who succeed and never offend again. There are, of course, some limited interactions with people while they are completing their community orders but this tends to be the exception rather than the rule. I would also point out that those who point to the ineffectiveness of short-term prison sentences when compared to community sentences in stopping reoffending only tell half the truth. In my experience, the vast majority of those given short-term prison sentences have previously failed on community orders, so to say that short-term prison sentences are ineffective is misleading.
	Nevertheless, I welcome the development of community -based sentencing options, such as restorative justice programmes, neighbourhood justice panels, community courts, and other initiatives which I know the Ministry of Justice is pursuing. I believe that these are worth while and worth supporting. The noble Lord, Lord McNally, went into some depth on his aspirations for neighbourhood justice panels and spoke with feeling-I read it with feeling-about the potential benefits of such a system. As far as I can see, the system will be based on the approach now taken with youths and locally recruited youth offender panels. As I said, I share his aspirations but I think that it is fair for me to point out the potential pitfalls of such a system.
	I believe that the courts and victims in particular could become separated from the sentencing process itself. At present it is rare for victims to be in court when an offender is sentenced, and it will be even rarer if there is a separate and subsequent neighbourhood justice panel meeting at which the activities of the community sentences are agreed. I accept that this is a conundrum with no easy solution that we also grapple with in youth courts. At its heart is the fact that there needs to be a level of trust and confidence between those who give the sentences and those who administer them: namely, the probation service and youth offender teams. Poorly administered community sentences can and do undermine both magistrates' and victims' faith in the sentence. Breaches in particular need to be brought to court in a timely manner.
	I have visited a number of unpaid work projects over the years and have invariably been impressed by them, but sentencers need to be confident that the programmes offered are realistic, achievable and above all properly administered. I will add that I believe that localism is a good aspiration for the courts system. Even in London, most people regard themselves as local to a particular area and would like to see community sentences carried out in their areas.
	I move on to the representativeness of magistrates. Magistrates, like jurors, should be drawn from the communities in which they live. It is desirable that they are drawn from all areas, and this is particularly important for areas where there is a high crime rate. Achieving this is difficult and I know that the matter is taken very seriously by the committees responsible for the recruitment of magistrates. Nevertheless, it is a fair generalisation that certain groups are underrepresented on the Bench. I would nominate Afro-Caribbean men as an important and underrepresented group. Having said that, I believe that Benches are quite diverse, but it is perhaps inevitable that those with the time to give to this public service predominate. The Ministry of Justice should play an active role not just in communicating opportunities to serve as a magistrate but more generally in promoting the role of the magistracy itself.
	I have two simple suggestions to increase diversity on the Bench. First, adverts for magistrates should be placed on buses and tubes. They used to be, but I have not seen an advert for many years, and I have long-standing colleagues who came on to the Bench after seeing those adverts. My second suggestion is that there should be a modest payment to local magistrates. We are not paid at the moment, whereas local councillors, tribunal members and Members of this House are paid. I remember that the justification for starting to pay local councillors was precisely to increase the diversity of those who serve on local councils.
	In conclusion, I have spoken about three areas: poor administration of the courts system, public perception of community sentences and the representativeness of magistrates. In each area, magistrates play a crucial role in the development of the courts system. All communities have the right to be confident that their local court services are delivered to a nationally consistent and high standard. It is of paramount importance that members of the public maintain their trust in the courts system and in the thousands of lay magistrates who sit every day to decide on matters that affect their fellow citizens. This debate was framed as a question. It is a genuine one and I look forward to the noble Lord's response.

Baroness Miller of Hendon: My Lords, as I am the first speaker after the introduction by the noble Lord, Lord Ponsonby, I thank him on behalf of us all for bringing this interesting subject to the House, and for the comprehensive way in which he dealt with it. I first declare an interest; from 1970 to 1993, when I was appointed to the Front Bench of your Lordships' House, I was a magistrate in both adult and juvenile courts. I assure your Lordships that in those 23 years I had my fair share of sleepless nights after some cases, worrying about whether I had done the right thing by certain defendants.
	We are all aware of the long history of the magistracy: both the lay magistracy and, since the 19th century, the stipendiary system. By performing duties as lay magistrates, non-lawyers have been one of the earliest examples of the so-called big society for centuries, and I have frequently explained to foreign friends that they are in effect a sort of jury with limited sentencing powers. The lay magistracy has long since ceased to be the province of the local squire, and no longer conjures up a vision of Tory ladies wearing flowery hats, although when I joined the Bench I was told-I ignored the instruction-that I was expected to wear one, with or without decorative flowers.
	As the noble Lord, Lord Ponsonby, said, magistrates' courts deal with well over 90 per cent of all criminal cases, as well as a wide range of civil matters. I will confine my remarks to their role in administering the criminal law. It is perhaps not quite good form for me to refer to one of my earlier speeches in your Lordships' House, but my maiden speech some 18 years ago was on the theme of law and order. The point that I made then, which bears repeating, is that the criminal law is there first and foremost to protect the public. It does this by punishing the wrongdoers-I will use the right word: criminals-and thereby acting as a deterrent to them and others from further offending. The possibility of rehabilitation is a very worthy objective, but one which perhaps all too often does not work.
	The recent outcry from the usual libertarian sources that the penalties imposed on the looters, arsonists and rioters last August were too severe was typical of the muddle-headed thinking that pervades some quarters. In arguing for the rights of the hooligans and criminals, they ignored the rights of the people who had their homes, businesses and jobs destroyed, in many cases just for the so-called fun of it-in many cases, it transpired, by people with existing records of criminal activity that had hitherto gone largely unpunished.
	The deterrent effect of the recent sentences will last only as long as the short-term memory of the potential perpetrators lasts: not long, I am afraid. What they will remember is that in future they should disguise themselves better from the CCTV cameras that, despite being decried in some quarters as an undesirable Big Brother device, did their job on this occasion.
	The police have the power to require people to remove masks. This is not quite adequate. On four occasions I have attempted to persuade political parties on both sides of the aisle to make it an offence to wear a disguise at any public demonstration, just as it is an offence to carry an offensive weapon. To no avail, I am afraid, but I repeat my appeal tonight.
	As to softer sentencing for the rioters and looters, I am reminded of the procession of mothers pleading for a light sentence for their child, who may have committed the most despicable offence, by telling the court: "He's a good boy really". Just like some of the recent offenders who to their horror, instead of a slap on the wrist, got a short-and sometimes not so short-sharp shock despite not having any previous convictions.
	Community service orders are regrettably inadequately staffed and funded and sometimes consist of futile lamppost-counting operations. Your Lordships may have read in the paper only yesterday of a man who had to be punished with a curfew for persistently failing to turn up for his community service duties on Mondays because he had a hangover as result of spending Sundays drinking in public houses and watching football. Where an unemployed man gets enough money to get drunk in a public house is beyond me.
	One problem we face is that things like ASBOs and referral orders, which we used to call probation, are in some cases regarded as a badge of honour. I well remember leaving court one day and a young man whom I had just put on probation was heard telling his friends outside that he had "got off". I will not repeat what he said about the magistrate who was stupid enough to do that. That typical attitude is part of the problem.
	The magistracy, both lay and stipendiary, as well as the rest of the judiciary, has a part to play in the big society. It is to ensure that law-abiding citizens who want to give something to society-big or small-can safely and freely go about their daily lives without fear for themselves, their homes, their possessions and their businesses.

Lord Patel of Bradford: My Lords, I greatly welcome this timely debate and add my thanks to my noble friend Lord Ponsonby for having secured it. I should declare that I am the honorary president of the Bradford Court Chaplaincy Service, which is, in my opinion, an excellent example of a court service involved in the big society, and I shall talk more about this unique service in a few minutes.
	This is a very timely debate because, as noble Lords are aware, the Constitution Committee of this House is currently hearing evidence on the judicial appointments process. I understand that there has already been much discussion about the importance of diversity in this process and about how it makes our judiciary not only more representative of the broader population it services but ensures that the integrity and authority of the courts are sustained. This is also a very important issue with respect to the big society.
	I am not a great fan of the term "the big society" as I am still far from clear that it actually means what it professes to mean. It sounds like the sort of thing that we are all involved in and suggests a model for society that is based on inclusion, but I do not see many plans for increasing inclusion. In fact, we are in grave danger of seeing a far less inclusive society as we continue to witness the retraction of the voluntary sector and restrictions in access to education. However, let us leave the political divisions aside for now and accept the big society for what it should be: a fair society, based on transparency and accountability in which everyone feels they have a chance and a stake.
	On such a definition the role of the magistracy can be seen to be vital. What is the magistracy? Well, most magistrates are, of course, justices of the peace, like my noble friend, who act on a voluntary basis to administer the law in our lower courts, and they do this with the authority of being highly respected members of their communities. Can a single magistrate represent all of the local community? Of course not, and we should not expect them to, but in terms of the big society and inclusion, we should expect the magistracy as a whole to be accessible to all and not limited in how we regard respect.
	Just as the big society is remarkably diverse, we need also to see a magistracy as a whole that is diverse. We should be accustomed to seeing more women and people with disabilities, more lesbian, gay, bisexual and transgender magistrates, more black and minority ethnic magistrates as well as those who are younger, older, of all faiths or none, married, single or in a civil partnership and, of course, wealthy or poor.
	If it is the administration of justice that we are speaking about, then we should ensure that there is also a justice of administration: a justice that reaches out to those who are excluded and actively brings them into the process and a justice that recognises that no single group can expect to make judgments in the interests of the community if it is not rooted in the community that it presides over. That is the real basis of respect and it is something that must be tangible.
	I mentioned that I am fortunate to be the honorary president of the Bradford Court Chaplaincy Service, and I want to end by talking a little about that service because it says a lot to me about the place of a modern court service in the big society. The Bradford Court Chaplaincy Service was established as a charity in 2008 with the aim of providing a multifaith chaplaincy service to all court users, including people of faith or with no faith, irrespective of race, culture, creed, special needs or sexual orientation. It is a truly inclusive service working as an integral part of the court and providing vital support, without prejudice, at what is often the most stressful period in someone's life.
	The service was founded by a former chair of the Bradford magistrates' Bench, Mary Carroll, together with four of her colleagues on the Bench, working together with local hospital chaplains and community members. This is very important because it was an initiative that really came from the local community, first through the wisdom and foresight of the JPs and secondly through the involvement of other local community members. It was also supported at the time by the then Lord Chancellor, my noble and learned friend Lord Falconer, which shows how much government has a role in supporting the big society. It really is the big society at work. Currently, the service has two part-time chaplains, one Muslim and one Christian, and around 40 volunteers who come from all walks of life in the local communities. They work mainly with defendants, many of whom are unrepresented and often very vulnerable. They also provide a service for all the staff of the court services. They provide 10 sessions in the magistrates' and coroner's court and nine sessions at the Crown Court every week. Last year, the service saw approximately 1,400 people.
	The volunteers and the dedication they demonstrate do not just happen; a service like this needs a great deal of support, time and resources. The big society cannot mean that everything is voluntary. Such an approach would not thrive as the court chaplaincy service demonstrates. The volunteers are supported by the part-time chaplains, who provide daily guidance, advice, training, ongoing mentoring and supervision. This ensures that the volunteers can get on to do what they do with confidence and skill and, of course, that confidence in the service provided by having a professional structure passes to those who use the service and those who refer people to it. That to me is the key to a successful big society approach in our magistracy combining the power of volunteers who come directly from the full range of local communities with the support of professionals and the wider structures of the courts and other partners.
	It is too soon to judge the full impact of this service, but I have no doubt that in time it will also become an important vehicle by which a more diverse magistracy is drawn from the local community. When we see this kind of initiative replicated across the country, then we will have a big society. For example, among many of its achievements, one of the most distinct and valuable aspects of the service is its contribution to community cohesion. By placing the focus of the service on chaplaincy and creating a truly multicultural service, the Bradford Court Chaplaincy Service has made cohesion a reality. This is a service that can work across the communities of faith in Bradford and with non-believers alike. The volunteers command a range of languages and dialects, cultural backgrounds and understanding and with all this bring a unique perspective on diversity into the courts. I cannot think of many examples of statutory services that have such an eclectic and diverse make-up of staff. So I hold this service up as an example for noble Lords in thinking about these issues, an example that I hope I have demonstrated captures the true essence of what the big society means and how the magistracy can play a significant role in its development and realisation.

Lord Thomas of Gresford: My Lords, when I was a very new, young and arrogant solicitor, I frequently appeared in the magistrates' court in the village of Ruabon in north-east Wales, an industrial part of Wales where coal was mined, steel was made, beer was brewed and chemicals were manufactured. I was always amused by the chairman of the local Bench, Lord Maelor, a former Member of this House, formerly Thomas Jones, the Labour Member for Merioneth. He lived all his life in nearby Ponciau, having worked down the pit as a young man. He later served as a non-combatant in the First World War. Indeed, he was imprisoned in Wormwood Scrubs for refusing to obey an order on the grounds of conscience. In court, he always went out of his way to identify the defendant who was before him: "Was his uncle a member of Capel Mawr?", "Did he live on Gutter Hill or was it Y Ffennant?" and so on.
	Lord Maelor taught me two lessons. The first was that order is preserved in a community not by the police, but by the people: the elders, the relations and the parents. By far the worst area for vandalism and crime in the area was the brand new housing estate, Plas Madoc. It was so new that only young married people or partners lived there. Though they had moved in from the settled villages around, there were no rules, no frowns and no social disciplines in their community. The second lesson he taught me was that he would give youngsters a chance, but would follow through his sentences by his deep involvement in the community and by his continuity in office. He was the one you would come back before, if you breached the probation order he was always ready to hand out.
	I have been greatly helped in preparing for this debate by a study carried out by Dr Jane Donoghue of the Centre for Criminology at Oxford, which was published only last Saturday, 29 October, as Anti-Social Behaviour, Community Engagement and the Judicial Role in England and Wales. I commend the study to the Minister. She points out that a central principle of the concept of the big society is co-production: how communities and individuals connect and come together to design and produce solutions to shared problems.
	In the context of the magistrates' court, the informal mechanisms of the past-that individual relationship between the magistrates and the community they serve-are of limited value in today's world. It appears that training designed by Her Majesty's Courts Service and the Judicial Studies Board in 2008 to support magistrates in community engagement has not been systematically implemented. Dr Donoghue's research shows that for the most part magistrates' involvement does not go beyond attending occasional meetings with their local ASB unit. The reverse side of that coin is that community groups have very little engagement with the courts. They live in two separate worlds.
	Participants from all the 17 ASB units studied expressed their disappointment and concern that magistrates so rarely engaged with the local community, and argued that a culture change was necessary, where magistrates would be required to allocate time to listen to the concerns of the local community. Some said that the courts do not think about the impact of an ASB on a community, that they do not understand the effect of ASBs on certain areas and that the community has no confidence in magistrates or the courts.
	On the other side, it seems that some magistrates worry about judicial independence. Dr Donoghue found that in one area magistrates discontinued an existing practice of making visits because they were concerned not to be seen to be influenced by local residents. In only one of the 17 areas studied was it felt that magistrates had a high level of engagement with the local community and were willing to talk to residents, attend local meetings and become involved in the life of the community.
	The other problem identified by Dr Donoghue's research was a lack of supervision. Ten of the areas studied had no experience of any kind of the supervision of court orders by magistrates or district judges. This was because there was a significant lack of continuity between repeat offenders and sentencers. It is highly unlikely that an offender in breach of an order will be seen more than once by the same magistrate or district judge. There is no formal system in place to ensure that an offender appears before the same sentencer in every court hearing related to their case.
	Dr Donoghue's conclusion is that most courts have not yet embedded into their structure the principles of community justice. Magistrates still see their role as adjudicators of fact and meters out of punishment and no more. If the concept of the big society is to have flesh put upon its skeleton, community engagement and problem solving in partnership with community groups and agencies should become a formal, standardised part of a magistrate's training and part of continuing professional development for existing district judges and magistrates.
	Nobody could ever question the commitment of Lord Maelor to his community, and the result was this: clear confidence and trust in the Ruabon magistrates' court by the whole community. He did not sit above the throng; he was a part of it, and it was a pleasure to appear before him, as I have no doubt the noble Lord, Lord Elystan-Morgan, would confirm if he were here.

Baroness Seccombe: My Lords, I spent over 30 years on the Bench, working with the most wonderful people. We came from a vast variety of backgrounds, all shapes and sizes, ages and colours, and reflected the community in which we lived. We had teachers, nurses, shop-floor workers, postmen, licensees, doctors, trade union officials, small shop owners-I could go on. We also had representatives of a vast number of voluntary organisations, including the WRVS, who incidentally also manned the refreshment bar. The experience they brought gave me a wealth of knowledge and added so much to our court life.
	It is important to get a balance in every way in the make-up of a Bench, members having left any partiality at home, and then, working as a panel, to try to achieve a just and fair result. One of my cherished moments was when, as a known active Conservative, I was elected chairman. I was told the qualities required to be a magistrate were: a desire to serve the community; an ability to listen and come to a view using sound judgment; an ability to understand and to communicate; and to have commitment and reliability. Above all, I have always believed that good old common sense goes a long way.
	I suppose you could say the magistracy was the original seed of the big society, having been in existence for hundreds of years, consisting of local citizens serving their local community. I believe that ever bigger and more intrusive government in recent years has sapped our strength and impeded anyone from daring to have imaginative proposals. Even if we had an idea, there have been too many obstacles in the way. For me, the big society means bringing decision-making back to communities so that local people have a real stake in running their own lives and supporting those who need a helping hand so that they can improve their lives. It means giving people the opportunity to bring colour and happiness to others less fortunate than themselves, while at the same time experiencing the genuine pleasure that can be had from joining a group of people who get things done, so contributing to a thriving community. Excessive regulation and bureaucracy have in recent years strangled initiative and enthusiasm and brought about a culture that the state always knows best. The big society is where we can all help each other as we try to do our bit to promote local well-being.
	Over the years I have been saddened by the closure of so many courthouses. I was always told that the magistracy meant local justice for local offenders in a local venue, but court closures have removed that vital local component. Of course, I understand that in painful financial times difficult decisions have to be taken. My experience tells me that it will be the same people who always volunteer and who will spearhead the big society. So please, whether it is the magistracy or the big society, let us return trust to local people so that they can make their local environment work for them in a unique and distinctive way. Let us keep as little regulation in our lives as possible.
	The big society is about service to others. It fosters responsibility and ever more closely weaves together an already complex and at times fragmented society. Service in all its forms is a most cherished principle that we must keep before us and applaud to the rafters. Let us ensure that we keep it small and bound to local communities.

Lord Dholakia: My Lords, this debate is timely but a little premature for my contribution. Let me explain. Earlier this year the Magistrates' Association set up a public engagement programme for greater understanding of people's views on the future of summary justice and the role of magistrates. I was privileged to be asked to chair this inquiry and it is right that I record my interest at this stage. I should also point out that I have served as a magistrate for over 14 years in West Sussex.
	The terms of reference of the inquiry were fairly wide:
	"To inquire into the role of magistrates and the future delivery of summary justice through engaging with experts and members of the public across the country".
	We have just completed this major exercise and hope to produce our report before next April. Our intention is to inform future policy development as affecting the magistracy. To avoid any confusion, let me add that "summary justice" is a term we apply to all forms of dealing with offenders other than in the Crown Court.
	The evidence was gathered by a panel comprising the chairman of the Magistrates' Association and three or four other national members involved in the criminal justice field. Local Members of Parliament played an important part in a number of consultations, with their overview of the magistracy in their constituency. The evidence-givers included local police, local victims of crime, local magistrates, professionals from intervention agencies, ex-offenders and local legal practitioners. The audience included the local public.
	This has been a remarkable and informative exercise. Let me spell out some of the key questions that were addressed. Do the public still support the concept of ordinary-that is, non-legally qualified-citizens being involved as members of the judiciary in the delivery of justice in England and Wales? Do the public have confidence in magistrates? Do magistrates provide a good quality of service? What do we mean by local justice; is "local" still a meaningful concept in that context? What is the role of magistrates in restorative justice? Should magistrates be involved in pre-court or non-court activities, such as the administration of cautions and local justice panels, to deal with offenders? Should magistrates be involved more fully in the management of sentences? Should magistrates be more involved in the rehabilitation of offenders and reintegrating ex-offenders into the community? Does the make-up of the magistracy properly reflect society? Are there any barriers to achieving this? Should courts be more accessible?
	Magistrates have existed, as has been explained, for more than 650 years, and we celebrated this in Westminster Hall earlier this year. In all these years, there have been many changes. At present, about 30,000 volunteers serve as magistrates. If the big society is looking for evidence of the involvement of volunteers, it need look no further; magistrates have set a very good example. We see people drawn from far and wide in our diverse community who use their local knowledge, supplemented by training provided by the Magistrates' Association and the Ministry of Justice. They contribute to maintaining peace and security in the community and deal with more than 95 per cent of cases before the courts. In the present economic climate, it is not a service that the Government can afford to pay for if they have to pay for it.
	Magistrates have been impacted by a number of external factors such as criminal justice legislation, which shapes the role and functions of the magistrates. Society being able to convey its confidence or lack of confidence in the decision-making process of the magistrates is also important. This was obvious when, after the recent riots, sentencing by magistrates generated a good deal of publicity. Let me in advance of the report give a flavour of what we found during our consultation. We expected criticism, but instead we found a good deal of understanding about the way magistrates performed their duties. Even victims and offenders had no criticism of the way they were dealt with by the courts.
	The incidence and nature of crime may vary from place to place and from generation to generation, but it is obvious that crime is something that all societies have to come to terms with in their own way. We can debate the underlying causes of crime, but most research and consultations have tended to refute rather than confirm the causes of crime and the effectiveness of punishments and treatment. Magistrates tread delicately but effectively, particularly when the public and political mood continues to be conditioned more by tabloid reporting than by the considered way in which magistrates reach their decisions.
	It is not possible to elaborate more fully at this stage on a number of our findings, but I trust that my noble friend Lord McNally will offer us the first opportunity to debate and discuss the report with his department. Suffice it to say at this stage that there was an emphasis in its broadest sense of diverting as many young offenders as possible from the criminal justice system. This is not a soft option but an entirely realistic approach to the strictly limited contribution that courts and prisons can make to reduce crime. We were told repeatedly that local justice should remain local in a magistracy that is representative of our diverse society. It is important that liaison with the probation service is enshrined in its duties and that its role should define the extent to which it should be involved in restorative justice, pre-court and non-court activities, the management of sentences and the process that rehabilitates offenders.
	In conclusion, the time is right for politicians and others to secure a clear shift in the public's perception of crime and punishment. Six hundred and fifty years of history and more than 30,000 volunteers as magistrates are the envy of the world. Let us make sure that they are not ignored in the challenging times ahead.

Lord Phillips of Sudbury: My Lords, I thank the noble Lord, Lord Ponsonby of Shulbrede, for instituting this debate. In the limited time that I have, I would just like to endorse the point, which was made very forcefully by the noble Baroness, Lady Seccombe, and others, that local justice is the essence of the work of justices of the peace. I have the greatest conceivable regard for the magistracy system, which has served this country for nearly 800 years, stands high in the reputation of the public, delivers the most extraordinary service, and itself is a demonstration of volunteerism that all recognise.
	However, the centralisation of the Courts Service has brought about serious drawbacks both to the public and to the magistracy. It is no longer justice of the people, by the people and for the people. The non-reporting now of cases because they are no longer within the purview of the local newspaper has been a disaster for the greater punishment of someone being held up to local ignominy as a result of a local offence. That is almost gone from the town I live in. Indeed, every one of the four courts in which I spent most of my first five years in the law-Sudbury, Long Melford, Boxford and Hadleigh-closed, and justice is no longer accessible, geographically or psychologically. I realise that this is more a problem of rural than of urban areas, but I ask that the Government take on board what has been said in this debate and at least stop further court closures and expensive centralised court systems and go back, wherever they can, to the dual or triple use of buildings, which rendered the expense of magistrates' courts absolutely minimal.
	I have two other quick points to make.

Lord Wallace of Saltaire: My Lords, we are very short of time in this debate.

Lord Phillips of Sudbury: I was told that I have four minutes but will take less time if I can.
	My first point is that unless the public understand the role of the magistracy, the magistracy will not be able to do its work as effectively as it has in the past. I fear that young people today do not by and large understand, largely because of the centralisation of courts, the role of JPs and the work that they do. I hope, therefore, that my noble friend Lord McNally will take back to Mr Gove, his colleague in the other place, the importance of maintaining citizenship education as a compulsory component of secondary education, because that is one upholder of knowledge about magistracy and magistrates' courts.
	My second point relates to the magistrates' courts mock trial competitions that are currently being run by the Citizenship Foundation-I speak here as its founder and still president-and the Magistrates' Association. More than 400 schools and 6,000 pupils are involved. It is a massively important element of the education of the public about the magistrates' courts system, but it is in danger because of the withdrawal of funding.
	I will say no more because I am getting serious looks from the Front Bench.

Lord Kennedy of Southwark: My Lords, like other noble Lords before me, I start by thanking my noble friend Lord Ponsonby for initiating this debate on what plans Her Majesty's Government have for the magistracy in the big society. It is a timely debate and we look forward to the Minister's response.
	I served for a number of years as a magistrate as part of the Coventry Bench and I have direct first-hand experience of the work, and the dedication to that work, of magistrates up and down the country. As my noble friend Lord Ponsonby said, magistrates, or justices of the peace, have been around for 650 years. They were "good and lawful men" back in the 14th century-and they were all men then-appointed to every county to "guard the peace". Perhaps it could be said that they were the trailblazers for the big society, or its original seed, as the noble Baroness, Lady Seccombe, said. I pay tribute to the work that they have done and continue to do to this day. They are men and women living locally, giving their time freely, committed to sitting a minimum of 26 half-days a year, and making a real positive contribution to their community. They are delivering local justice for local people by local people. The former Lord Chief Justice, Lord Bingham of Cornhill, observed that the lay magistracy was a "democratic jewel beyond price".
	Noble Lords, will be aware that all criminal cases start in the magistrates' court and that more than 95 per cent are concluded there. At this point, I pay tribute to the work of the Magistrates' Association in the support, advice and guidance that it gives magistrates. It was 90 years old recently and has made an important contribution to the development of the magistracy over that time.
	The big society as an initiative is something that we hear less about from the Government today than we did at the start of their period of office. But we can all point to organisations, people and initiatives that make a welcome and positive contribution to local communities, and lay magistrates fit that bill wonderfully. Magistrates are appointed by the Lord Chancellor and the Secretary of State for Justice on the advice of local advisory committees. The appointments process is rigorous in its approach of selecting the right people to undertake this important work.
	Having an appointments process that is rigorous and robust but also adaptable is paramount to ensuring that we make the best appointments. Can the noble Lord, Lord McNally, tell us if the Government are looking at the appointments process of both lay magistrates and the advisory committees to ensure that we have the best chance of appointing people who truly reflect their local communities? How are the Government engaging with employers and the voluntary sector to ensure that there is a steady stream of applicants? Are they working with, for example, local Sure Start centres to get younger women with children to consider putting themselves forward as magistrates? My noble friends Lord Patel and Lord Ponsonby made important points regarding diversity.
	I am sure that noble Lords are aware of the Magistrates in the Community programme, which was started by the Magistrates' Association. In recent years it has increased the public's awareness of the role of magistrates in the criminal and civil justice system. It involves magistrates attending schools, colleges, community groups and employers to give presentations and to discuss what magistrates do and how they are appointed.
	Quite rightly, the Government want to make good use of community sentences. The local crime community sentence programme builds on the success of the Magistrates in the Community project and involves magistrates and probation officers together speaking to community organisations to deliver information on how offenders are dealt with when they have committed a crime that has resulted in a community punishment. When the noble Lord, Lord McNally, responds, can he tell the House what value the Government attach to these initiatives? What support are they giving them and what do they see in terms of further development?
	Both the previous Labour Government and this Government recognise the importance and worth of real community engagement in criminal justice strategies. It can increase confidence in the criminal justice system and help to diminish anxieties about crime, although some would say-I should say at this stage that I do not agree with them-that this raises concerns about judicial independence, as the noble Lord, Lord Thomas of Gresford, told your Lordships' House. It is an obvious and natural progression, and essential for enhancing community confidence in the justice process. Can the noble Lord also give some insight to the thinking of the Government and perhaps tell the House how he sees this being further developed? When does he expect the training material and other briefing devices to be fully reflective of this?
	In conclusion, I am aware that I and other noble Lords have posed a number of questions to the noble Lord, Lord McNally, and it may not be possible to answer all the points in the time that he has. If that is the case, I should be delighted to receive responses to the points raised in writing. I again thank my noble friend Lord Ponsonby for initiating this debate. We have had excellent contributions from all around the House and, like others, I look forward to what the noble Lord, Lord McNally, has to say.

Lord McNally: My Lords, first, I thank the noble Lord for the courtesy of those last remarks. Indeed, if I am to sit down at the right time, I will not be able to cover all the points that were made. However, I will write to all noble Lords if I do not manage to cover all the specific points. I also thank the noble Lord, Lord Ponsonby, for introducing this debate. As he knows, my first job in politics was working for his late father, who I am sure would have been proud to see the noble Lord introduce this debate. I am also grateful that we have had the experience of a number of magistrates, including the noble Lord, Lord Ponsonby, my noble friends Lady Miller and Lady Seccombe, and the noble Lord, Lord Kennedy of Southwark.
	One of the concerns raised by the noble Lord, Lord Ponsonby, was the poor administration of the court system. We are looking at that in terms of introducing new technologies as well as perhaps also bringing forth legislation at some stage to improve court management. I agree with him that courts should retain the personal touch; I take that point. The noble Lord, Lord Ponsonby, and a number of other noble Lords referred to community sentencing. He is right that I want us to explore more community sentencing. However, as the noble Baroness, Lady Miller, reminded us, if such sentences are to carry public respect they will have to be tough and effective.
	Noble Lords referred to diversity. At the Ministry of Justice I am the Minister with responsibility for encouraging diversity. It has to be said that one of the encouraging things about the magistracy is that it is a whole lot more diverse than other parts of the judiciary. Other than make that point, I shall say no more. A number of good suggestions were made this evening. I will not make the usual point that times are hard and question whether we can afford to advertise on buses. However, I will take back the suggestions made by the noble Lords, Lord Ponsonby and Lord Kennedy, and others about how we encourage technology.
	I hear what the noble Baroness, Lady Seccombe, and my noble friend Lord Phillips said about court closures. There is a whole variety of reasons why we have moved to court closures, including the inadequacy of some of the older courts and the increased use of technology. We will explore that, and I think it will be a factor in making the courts more accessible.
	On recruitment and retention, I know that my honourable friend Jonathan Djanogly and my right honourable friend Nick Herbert in the other place are in close and regular contact with the Magistrates' Association. Indeed, Nick Herbert is addressing the Magistrates' Association conference on 8 December. However, I take the point that the noble Lord, Lord Kennedy, has made. I will go back to the department to see how much outreach we are making. It is extremely important that we encourage as many people as possible to come forward in terms of encouraging diversity.
	I was fascinated by the comments made by the noble Lord, Lord Patel, about the court chaplaincy service. In the big society, the churches, the religions and the faiths have a big part to play. They already have a structure of which we should make use. Two of the most fruitful visits I have made were to Norwich and St Albans, where the cathedrals are used not just as faith centres but as community centres. What the noble Lord described about the chaplaincy service seems to be an inspirational example of how this could happen.
	The noble Lord, Lord Thomas of Gresford, made two points. The first was his memories of the local magistracy. My colleagues back at the MoJ are aware that I frequently refer to Tommy Croft and Billy Quinn, although they are not names that have run down history. I was born on an ICI estate and Billy Quinn and Tommy Croft were two local magistrates. They both worked in the local ICI plant but, my God, they knew the community and their community knew them, which is always an interesting aspect of the magistracy. On Dr Jane Donoghue, I have not had the benefit of that study but I will certainly follow up on that. From what my noble Lord had to say, there are some interesting points about training and engagement.
	We welcome the research referred to by my noble friend Lord Dholakia in his intervention. I think that it will help to inform our thinking on the future of the magistracy, particularly in relation to plans for developing neighbourhood justice. I certainly hope that when the report is ready, we will have a dialogue on it. I would welcome that.
	It has been pointed out a number of times that this year is the 650th anniversary of the magistracy. I was pleased to be at the John Harris Memorial Lecture given by the Lord Chief Justice on this. As someone who is a kind of fake historian, I liked the idea of the concept of the King's peace being set in statute in 1361 and the novel proposition that decent members of the community, not themselves lawyers, should be vested with the power to administer justice. That is one of the things which has been of lasting value to the magistracy. It comes from local communities and its strength lies in the fact that it is still the bedrock of our judicial system. My noble friend Lord Phillips referred to the mock trial competition. It is true that we have had to reduce our support for that. We still give it money and of course we also provide the court and staff for the competition, so we have not abandoned it entirely.
	As the noble Lord, Lord Kennedy, intimated, the problem with these dinner time debates is that to do justice to those who have contributed, the Minister should really be given half an hour to speak, but I will cover some of the issues in writing. What I would say, however, is that my gut instinct, going back to Tommy Croft and Billy Quinn, is that as long as I am a Minister, I will take the role of the magistracy as the bedrock of our criminal justice system. Some of the ideas put forward in the debate tonight will be taken back and studied very carefully. What I want to say as well is that although we are looking at other proposals such as neighbourhood justice and restorative justice, they will be seen as complementary to and in no way undermining the magistracy. I look forward to a dialogue with the magistracy and I will study the suggestions that have been made in this debate, not least those on how we achieve greater outreach so as to increase diversity. Again, I thank sincerely the noble Lord, Lord Ponsonby, for promoting a debate which has been extremely worth while.

Health and Social Care Bill

Main Bill page

Committee (2nd Day) (Continued)

Amendment 12
	 Moved by Lord Warner
	12: Clause 2, page 2, line 16, at end insert-
	"(c) the clinical integration of the delivery of health and social care"

Lord Warner: My Lords, as they say in commercial television, welcome back after the break. In moving Amendment 12, I shall speak also to Amendments 16, 17, 182, 183 and 184 tabled in my name and those of other noble Lords. I have also added my name to Amendment 18 to which my noble friend Lord Rooker will speak-I hope. The theme of these amendments is that of giving greater prominence in the Bill to the issue of service integration not just within NHS services, but across the health and social care boundary. At the same time, I will try to give some clearer meaning to this term by offering a definition in Amendment 184. This is a very complex issue and it has not been helped, if I may say so, in some of the public discourse by the way that the term "integration" has been used in a wide variety of ways by different people.
	I shall start with some remarks about integration and its relationship to competition, which has been the subject of quite a lot of debate around this Bill and NHS reform. In recent months, the term "integration" has been bandied about as a kind of panacea for the NHS in the challenges it faces, but with little clarity about what it means. The Future Forum put the issue of integration on the map in its report. Some of this affection for integration has grown because it has been seen as a useful term by opponents of competition. They have tried to make the argument stand up that somehow if you have integration of services, you cannot support competition because the two are incompatible. I do not believe that to be true. It is perfectly possible to have the right kind of integration within a competitive market. Kaiser Permanente, among others, has shown this to be the case in the United States. Indeed, it was the very competitiveness of that market which caused Kaiser to offer patients more clinical integration in order to survive and flourish in the marketplace. That integration was done on the basis of reducing the use of in-patient hospital services. It is worth noting that there are NHS-Kaiser Permanente partnerships in six areas of the NHS which are adapting lessons from Kaiser's experience in the US to apply in this country.
	Having got that off my chest, I turn now to the issue of how integration and competition can coexist and how we need to be clear on what we are talking about when we use the term "integration". There is, I suggest, good and less good integration. Much so-called organisational integration is effectively mergers of providers with little benefit to patients and often involving a reduction in choice. We see this in integration horizontally across organisations of the same kind and vertically between community and hospital services. The former is often done to save costs and reduce competition, while the latter is too often a way of securing patients for in-patient services and maintaining hospital income. Some will disagree with that, but it is certainly a perspective we should think about. Organisational integrations of this kind have sometimes fallen foul of the competition and collaboration panel. They are to be viewed with a sceptical eye, although I accept that integrated commissioning can be a major benefit for patients.
	The integration, however, that is likely to benefit patients the most, and the cost structure of the NHS the greatest, is integration that brings together the assessment and delivery of health and social care services at the point of assessment and delivery to the individual person. This is the type of integration we have attempted to define in Amendment 184. At a time when such a large part of the NHS's work involves patients with long-term conditions, who often require social care as well as healthcare, this is the type of integration that NHS and social care organisations and personnel should be focused on, particularly those commissioning services. These commissioners need to look for a new breed of service integrators who can take responsibility for integrating services for individuals across the health and social care boundary or divide, depending on your perspective. The Conservative's community care reforms of 20 years ago produced care managers as integrators of social care in a mixed economy of providers. We now need to apply the same thinking to the whole spectrum of health and social care, especially for those with long-term conditions.
	None of this will be easy, but if the NHS is to meet the financial and other challenges it faces and reduce its dependence on expensive, often unsustainable and often inappropriate, acute hospital services, it must begin the process of improving service integration at the level of the individual and not just the organisation. It is important that we use the Bill to set a new direction of travel on service integration for both the NHS and the social care worlds. The word "integration" needs to move from a term of rhetorical flourish to a reality that benefits people at the local level.
	Of course, simply putting words in a Bill will not on its own change things; they will need to be backed up by changes in the professional culture, the use of IT and the financial reimbursement system. Later in the Bill I shall move amendments to help integration in the areas of tariffs and the use and extension of an electronic patient record. In the mean time, I want to establish a bridgehead in the Bill with this group of amendments that give more prominence to integration and try to define it. My co-signatories will expand on some of the arguments.
	I should make it clear that I do not regard the wording of these amendments as the last word on the subject. I am sure they could be improved and they may have consequences for other parts of this leviathan of a Bill that we have failed to spot. I also recognise that the Labour Government had integrated care organisation pilots and that the Department of Health and the King's Fund are working on the issue of integrated care following the Future Forumreport. It is no purpose of these amendments to pre-empt or damage that work. I and my co-signatories are seeking to establish today whether the Minister is up for amending the Bill to give more prominence, more precision and greater reality to the term "integration" to shape the future commissioning and provision of services in ways that will benefit patients. We will be glad to sit down with him and his officials to improve the wording of the amendments and their placement in the Bill. I beg to move.

Lord Patel: I support the amendments to which my name is attached. This is an important issue. As the noble Lord, Lord Warner, mentioned, at some of the seminars we heard the word "integration" used in different forms with no clear definition of what it meant.
	Future Forum, of course, put integrated care at the heart of NHS reform, but who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider? What can clinical commissioning groups do to stimulate providers to work together to meet the needs of the patient?
	As the noble Lord, Lord Warner, mentioned, integrated care takes many different forms and may involve whole populations; care for particular groups or people with the same diseases; and co-ordination of care for individual service users and carers.
	There is good evidence of the benefits of integrated care for whole populations and for older people. There is mixed evidence of its benefits for people with long-term conditions such as diabetes and for people with complex needs. I will return to that later. Of course, Kaiser Permanente is one of the good examples of managing integrated care for long-term conditions but there are not that many.
	The commissioning groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. That includes advice on matters of contracting and procurement, outcomes and quality measures to include in contracts, and the tariffs and incentives to use. Work is also needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective care. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more co-ordinated, unplanned care when funding is tight. That will have to involve the providers.
	Other factors that appear to support integrated care commissioning include robust performance management, sufficient time and resources from the provider side, and adequate investment in the main stages of the commissioning cycle, such as needs assessment, service design, contracting and tendering, and outcome-based evaluations. As management and resources shrink, there are obvious questions about whether clinical commissioners will have the necessary time and support to plan and contract for changed services in profound ways. To be more specific, there need to be resources at a national level to avoid commissioners at a local level reinventing the wheel many times over.
	To turn briefly to long-term conditions, in the next decade the health and social care system will have to contend with an ageing population, increasing numbers of people with complex long-term conditions, budget constraints, increasingly sophisticated and expensive treatments, and rising expectations of what healthcare services should deliver. An integrated care approach to meeting these challenges-through better co-ordination of health and social care services, reducing the fragmentation or duplication of care-has the potential to improve support for the management of these complex needs.
	Let me share a true story as an example of the issues here. Somebody approached me just before Second Reading of the health Bill. I mentioned this at one of the seminars and have since checked the authenticity, and visited the person in the hospital where care is currently provided. This person has insulin-dependent diabetes and was found to have an ulcer on the leg. He saw his GP who suggested that dressings would be required to try to heal the ulcer. During the process of that treatment, a specialist diabetic nurse who came in contact with the person suggested that they might be better getting advice from a specialist unit. While the GP suggested that the care provided was satisfactory, the person demanded to be referred to a hospital. By the time he got to the hospital, three of his toes were necrotic. They had to be removed last week. The patient needed an angiogram to decide whether the blood flow was satisfactory so as to put stents in so that he would not lose further parts of his limbs.
	As we all know, it is crucial for diabetic patients to avoid certain complications. Good glycaemic control is required to manage that, so that their sight and renal functions do not deteriorate, their cardiovascular functions remain good and they also do not lose limbs because of necroticism. This shows the need for integrated care that requires the whole team to work together. For a start there need to be good records and IT that can transfer information between different carers, GPs, practice nurses, specialist nurses, and specialists in diabetes. There needs to be screening for eyes, kidneys, blood pressure, diet, cardiovascular disease and so on. Most importantly, there needs to be joint training for people who look after these patients, whether that is in the community or in specialist units.
	If you are looking for good outcomes for patients, integrated care is what matters. It should be based on the journey of care-the patient pathway of care. That is what we need to establish. I hope, as the noble Lord, Lord Warner, said, that we can have further discussion to try to improve this Bill and see if we can deliver that.

Baroness Murphy: My Lords, this is a topic very close to my heart. The delivery of social care is almost wholly towards people with health problems; if you do not have a health problem, a disorder or disease, you will not be in receipt of social care. But we have always had this curious distinction between who delivers what. We have had these great silos whereby enormous amounts of spending in the health service would be better spent transferred to social care services. We have known that for years and years, but it has not really happened as fast as it should have done.
	The commissioning and delivery of services has been almost wholly down these isolated silos. We have tried to chisel away at this over the years with joint trusts for delivery of services to children and other joint trusts for delivery of services to mental health, and so on. But for the mainstream older person coming through healthcare services, we have not had that integration very effectively, and we have therefore wasted money buying health services when we should have been buying social care services. So it is crucial that people get better cost-effective packages of care, which include the whole pathway.
	It is also true that we have a system at the moment whereby in the past 20 years we have moved hundreds of thousands of seriously disabled older people out of NHS care into independent sector nursing homes and, in the beginning, local authority care homes and contracted private homes, leaving behind the teams of people-healthcare professionals, medics and nurses who used to care for them in hospitals-completely isolated back in the hospital. They are not delivering those community services that the independent sector nursing homes and local authority care homes so desperately need to provide-comprehensive health and social care service in residential care. It has always seemed extraordinary that we have allowed these silos to grow up, whereby the person sitting in the hospital, the consultant geriatrician or the psychogeriatrician, does not think that it is their business to provide a service for the wider community of patients in their patch. It seems extraordinary to me that we could have got ourselves into this position.
	We need something to move back again to a situation in which people think epidemiologically about a community, about how the best services could be provided from vertically integrated care between hospital and community services-and of course that community care must start with what comes from primary care-but also fundamentally from what is commissioned from social care as part of the package. Perhaps we can get it in somewhere in this Bill that we need to do this. We all know about Kaiser Permanente and the examples of how it works in the States. It works very effectively when you can commission from a range of services across health and social care directly. That makes a great deal more sense than trying to narrow the trenches; a trench always pops up somewhere else when you chisel away at a trench between local authorities and NHS authorities. You do not need to do that if you are very clear about commissioning a package of services across the divide and across NHS primary care and social care. This is extraordinarily important as the population continues to age and, without it, we will not be able to generate that wonderful £20 billion of savings that we are always going on about. We will get better value for money if we contract across an integrated care pathway across health and social care.
	I do not know whether this is the right point to get this proposal in. Like the noble Lord, Lord Warner, I am sure that it should go somewhere and that we should have a real commitment in the Bill. If it is the right point, we can get people to translate this into the sort of unbundled tariff that we need to get the financial packages right and move away from the counterproductive system of payment by results. Unfortunately, that again tends to fossilise an old-fashioned way of doing things, which is too expensive. I give my full support to this amendment.

Baroness Pitkeathley: My Lords, my name is added to some of these amendments and I will add little to the eloquent speeches of my noble friend and of the noble Baroness and the noble Lord from the Cross Benches. I want to endorse only the important points of principle that they have set out. As someone who has spent a large part of a long working life at the margins or the crossover points between health and social care, I am only too well aware of what goes wrong if you do not have proper integration. It is very important, as the noble Lord, Lord Patel, reminded us, to come at this from the experience of the patient, the user and the carer. Their needs rarely come neatly packaged as health and social care; there is always crossover between them. That is especially true in the case of long-term illness but it is also a concern to those who have had an acute episode, especially in these days when people are discharged early from hospital but still need medical, nursing and social care at home.
	Almost 40 years ago, I wrote a book called When I Went Home, a study of patients discharged from a local community hospital. One patient I interviewed said to me, "What I don't understand is why they don't talk to each other. Why did they discharge me without arranging it with my family-without even telling my family I was coming home-and why weren't the services I needed at home all geared up for when I got there?". I have lost count of the number of times that I have heard this story repeated over the years. Patients, users and carers do not understand different funding mechanisms, professional boundaries or sensitivities about exchanging information-and why should they? We have been saying for at least 40 years that we must improve integration. Let us for goodness' sake use this reform as a means of achieving more commitment to integration, to which everyone pays such a lot of lip service but which in reality is still sadly lacking.
	I must emphasise that we are at a point where not only do we risk not making integration better but where it could become worse if we do not really emphasise the importance of integration in this legislation. I am thinking of things such as the pressure on local authority budgets and on the voluntary sector, which is so often such an important part of an integrated care package. I am thinking of the mismatch in timing between the reforms in social care and those in the health service. I always think, too, that we should remember that it is people, not structures, who promote integration. Those currently employed in health and social care are working in a confused situation. They are often uncertain about their futures and their working relationships. They are therefore really not in a good place for cutting across professional boundaries and perhaps giving up some of their power to develop the flexible ways of working which are so necessary for integrated services. We owe it to them, as well as to the patients, users and carers, to be as explicit as possible about the importance of integration. I hope we will do that in this Bill.

Baroness Cumberlege: My Lords, I would like to make a contribution. I was very interested that the noble Lord, Lord Warner, said in his introduction that he felt that integration was sometimes used as a defence against competition. He cited Kaiser Permanente, as did the noble Lord, Lord Patel. Closer to home, I was really interested to see that Assura Cambridge-Assura is an independent company-was involved in an integrated care organisation. It was a pilot that was designed to improve the quality of end-of-life care locally and to ensure that 50 per cent of patients who knew they were dying would do so in a place of their choice. After five years, the aim is to increase this figure to 75 per cent.
	Assura Cambridge, which is a partnership between Assura Medical and 16 GP practices in Cambridge, worked with a range of care providers to plan, co-ordinate and improve the delivery of care to patients in the last year of their lives. The project team was led by Assura Cambridge and included representatives-this is important because it shows real integration-from Cambridge University Hospitals NHS Foundation Trust, Cambridge Community Services, NHS Cambridge, which is the primary care trust, the Cambridge Association to Commission Health and the DoH integrated care organisation pilot team. This collaboration and partnership had a very simple system, which was to use "just in case" bags. The system was adopted to ensure that GPs had the appropriate medicines to hand for terminally ill patients in advance of their need. By taking this very simple step, the integrated care organisation was able to ensure that 87.5 per cent of deaths occurred in the patient's usual residence or place of choice, compared to only 50 per cent of deaths without using the system.
	In this case it was Assura Medical that acted as the glue to ensure that collaboration brought about an integrated solution, which has since exceeded the project's aspiration. That is very interesting: it needed someone from outside the NHS to bring all these people together. When I talked to some of them, they said, "We haven't got the time to do that. We just couldn't fit all that together". It was an outside organisation that was able to do that.
	Recently I went to the Royal College of GPs' annual conference in Manchester-no, I am sorry, Liverpool; I know there is a great difference between the two, but I have been travelling a lot recently. There was great debate about the ethical issue of GPs commissioning. The person promoting this was Professor Martin Marshall. He asked the audience of GPs-the place was packed-what the most frequent diagnosis that came through their surgery door was. As you might expect, the GPs mentioned coronary heart disease, diabetes and so on. Professor Marshall said, "No, it's LIS", and everyone looked very puzzled. He said, "Lost in the system". I thought that was interesting. "Lost in the system" is the problem when we do not have integration.
	It seems to me that integration happens on three levels, so maybe we have to define it more closely. The first is within community services. A GP said to me the other day, "District nursing-they're the enemy". When you start at that base, we have an awful lot of work to do just to get integration within the community. As the noble Lord, Lord Patel, said, you have to get the whole team to work, and to work beyond the team as well.
	I have done a bit of work with maternity services. This is the next tier up-integration between community and hospitals. One of the things that we have tried very hard to do is to get midwives to have caseloads, so that they are there when the woman is pregnant, looking after her. They will perform the delivery, which will not necessarily be at home-it can be in hospital-and then do the postnatal care. It is brilliant. It is what women want and it provides continuity and integration. Try getting that to work-it is very difficult, because of the territories; hospitals often do not want the community midwives to come in, on to their territory, and perform the delivery. Integration happens in some places but it is very hard to roll out. That is the second tier-the hospital and community tier.
	The third tier comprises social services and health and is a very difficult area, as the noble Baroness, Lady Murphy, said. It is about silos and hierarchies. It is not just about territories; it is about who employs the staff. Having spent a few days in Torbay, I was very interested to see that the social workers there are now employed by the PCT. The social workers have been TUPE-ed across. A single organisation employs both health and social services staff. I went to some of their meetings and was very impressed by the integration that they had achieved. That was very encouraging.
	I note that new Section 14Y on page 37 contains a duty to promote integration as regards CCGs. Subsection (1) states:
	"Each clinical commissioning group must exercise its functions with a view to securing that health services are provided in an integrated way where it considers that this would-
	(a) improve the quality of those services",
	and reduce health inequalities. The new section goes on to say a bit more about integration with social services. Health and well-being boards have a duty to encourage integration under Clause 192 on page 193. Subsections (1) to (4) of that clause contain a lot of detail on that duty. Clearly, there is a great will within the Government to achieve integration. I am sure that the noble Lord, Lord Warner, who is extremely persistent and determined, will keep up the pressure in this regard and we will see how this all pans out.
	However, I go back to the level of the individual and to what one of the amendments of the noble Lord, Lord Warner, says about joint assessments. That is absolutely critical for an individual. Given the personalised budgets whereby individuals can spend the relevant money as they wish, there will be superb integration-as long as we can get some joint budgets-because those people do not see the boundaries that I have mentioned. They do not care who employs who. They want a service that works for them. When they are in charge, have the money and can choose the services they want within that budget, we will see a very different health service and provision of social services. We will then see real integration.

Lord Turnberg: My Lords, I rise to support these amendments. I agree with virtually everything that my noble friend Lord Warner has said. However, I disagreed with the assertion that Clause 2 may not be the right place for the measure. Clause 2 is headed "The Secretary of State's duty as to improvement in quality of services". If there is anywhere that needs improvement, it is in the integration of services. Therefore, I think this clause is the ideal place to insert the measure.
	There is general agreement that the principle of seamless care-that is another term for integration, from the point of view I am talking about-for individual patients is a good one and we should support it. By that I mean the ease with which patients can move between one set of carers, hospitals, homes and social care and another. At the moment it does not seem to happen as well as it should in many places, so the Bill is, theoretically, a way in which we can stimulate the mechanism by which it can all happen. However, for integration of care between providers to happen with the minimum of disruption to the individual patient, we need to ensure that there is much more collaboration and consultation between them. It is not only between doctors, nurses and other carers that this collaboration is needed, but particularly across the divides between those funding and managing the different care streams. That is where these amendments can help.
	At the moment, we have patients waiting for far too long, as we have heard, in an environment unsuited to their needs-elderly patients sitting in acute hospital beds waiting far too long to go home or into social care. A range of problems get in the way, such as a lack of planning, a lack of facilities, or closure at the weekend of offices where these arrangements should be made. To me, integrated care means the close working arrangements that allow not only the rapid and efficient transfer of patients but the ability to discuss the best course of treatment for a given patient. It means the ready consultation between different specialists, perhaps in different hospitals. It means different trusts, whereby patients can have access to the best treatment available.
	I am reminded of the example of orthopaedic surgeons, some of whom specialised closely in hand surgery or re-do hip surgery-second operations on hips that have gone wrong the first time round. Those highly specialised orthopaedic surgeons are not available in every hospital. The ability of one group of orthopaedic surgeons to transfer a patient to the best care possible in another hospital should not be thwarted. We should not be putting any barriers to ready consultations and, if necessary, the transfer between hospitals of patients seeking the forms of treatment that are most relevant to them.
	Of course, competition is seen as a driver to improving standards. However, let us be clear; there must be a balance between competition and integration, and between competition and collaboration. I am pleased that Monitor will, I believe, have a role in improving integrated care. I hope that we can persuade the commissioners and providers to support integration also. That is why I support these amendments.

The Archbishop of York: My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State's duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty-already provided for in the first two subsections-will not be carried out. Integrating the delivery of services will be important.
	I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.
	It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.

Lord Davies of Stamford: My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.
	Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire-and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter-that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis-some old person who can no longer cope in some way-his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.
	Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week-it is not an exceptional situation-to patients, their families and carers, who are the victims of it.
	The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.
	Sadly-I deeply regret this-the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice-the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.
	I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?
	My second question to the Government is: given that they did not decide to go down that route, what contribution to a solution to the problem that I have just outlined is represented by this Bill? Of course, I have tried to answer that question for myself by reading the relevant clauses of the Bill but I have not come up with a clear or definitive answer-one that satisfies me. I think that the answer is that it makes no change at all. So far as I can see, Clause 10 simply incorporates into the Bill and carries forward the duties currently imposed on health authorities and PCTs by Section 3 of the 2006 Act. I do not have that Act in front of me but, if I recall correctly, Section 3 includes a reference to aftercare. PCTs can, if they wish, commission aftercare, which is obviously a social care issue, although I have never heard of them doing that.
	Similarly, what about the influence of hospitals on the plans of local authorities, and the influence of local authorities on the plans of commissioning groups and the future clinical commissioning groups? Again, it seems that Clause 187 of the Bill simply replicates the provisions in the 2006 Act for local authorities to have the right to consultation and influence over the plans of NHS bodies. Therefore, it does not make any substantive change. It does not do anything that addresses the problems of articulation between the NHS and particularly the secondary sector-the hospital sector-and social care. I may be wrong in that. I hope that I am and, if I am, I ask the Minister to tell me why I am wrong and in what respect the Bill genuinely attempts to address this major structural problem, which has been around for a long time. It would be a wonderful opportunity for this coalition Government to do something about this problem, if they have the will to do so. I hope that the Minister is going to tell me that I have missed something and that this issue is addressed in Clause 195 or whatever. Perhaps he is going to tell me that there is nothing in the Bill but that he intends to put forward regulations to address the problem, in which case I shall welcome that statement and listen with great interest to what he has to tell me. This is a major national problem. There is a serious failing in the way that our healthcare service operates that needs to be addressed.
	I make one final comment on integration, but integration of a slightly different kind. The Government are consulting at the moment with a consultation document about the future of social care. I have read that document and responses have been asked for in writing by 2 December. That is extraordinary, is it not? The Government bring forward a new Bill and we are starting the Committee stage, which will probably go on until after 2 December, although I have no idea for how long-none of us does. At the same time, they are consulting on a document about social care. One might think that they would design a new social care system, look at how it needs to be integrated with the rest of healthcare and then come forward with a coherent Bill. Frankly, it is the most extraordinary way of doing anything. It would be the most extraordinary way of running a railway. In my view, it is the most extraordinary way of legislating and the most extraordinary way of running the health service. I hope that the Minister is not too upset by my strictures, which are not personally addressed to him, but an answer does seem to be required as to why these two initiatives seem to be proceeding in parallel with no apparent integration at all.

Baroness Jolly: My Lords, I think it is entirely appropriate that integration is included in the Secretary of State's duty with regard to the improvement of the quality of services. I do not think that anything can improve services more than making them patient-centred, and it is the whole business of integration that will make services focus on the patient. Therefore, we welcome the language. Again, I do not know whether it is in the right place but we welcome the fact that it is there, as well as the definition.
	Integration is critical. We have heard about the savings that we need to make, and integrating care is cost-effective as well as being good for patients. I want to talk briefly about social care and the community, and about how the community care too. I come from the south-west, so I will also mention Torbay, which is the jewel in the crown in our neck of the woods. The thing that has worked in Torbay was that when PCTs were set up, the local council decided that, working with the area health board, it did not want a PCT, it wanted to have a care trust. The key to the whole thing was having not only shared governance but a shared budget. There was only one pot of money to fight over and all decisions were made by councillors, non-execs and the executive round the same table. So, in Torbay care is totally integrated.
	In Plymouth there is another small integration pilot going on in the DGH whereby many patients from Cornwall go over the border to the acute hospital. Somewhere in the region of a quarter of Cornish patients do not go to Truro; they go to Plymouth. Discharge has historically been a huge problem-bed blocking, Friday afternoons, all the usual sorts of things. It was a joint appointment between the PCT and social services. A social work team was put into the hospital and they liaised with all the right people when discharge was coming along. There was liaison with patients, carers, GPs, social services, care homes, domiciliary, district nurses-the whole thing-to make sure that when the patient was ready to leave the acute service they went to their next port of call and everything was all teed up ready for them to go on. That was effective. It saved time and it was much better for the patient.
	I return to the amendments. There is a whole series of interesting additions which are all to be outcomes-but outcomes need measuring. So how do we measure, and what are the indicators for the effectiveness of integration of services, or the equitable provision of care, or the safety of the service? These are good things to achieve and aspire towards but I am not sure how they will be measured. I would like some clarification from the Minister as a general point. Some of the outcomes from the original Bill were added to. How will the success or otherwise of achieving these outcomes be measured and how will it be reported?

Lord Kakkar: My Lords, the noble Earl, in his thoughtful introduction of the Bill on Second Reading, identified the challenges that face all mature healthcare systems such as our own in terms of the changing population demographics, with an older population, more chronic disease and the need to improve clinical outcomes through integration of the new technology innovations and pathways of providing care.
	In trying to understand how those important objectives will be achieved by the Bill we need to try to identify potential strategies. One of the most important is to ensure that the health service focuses on integrated care in the future. We know from quite a lot of important experience around the world that integrated care has the opportunity to improve clinical outcomes. We have heard of the patient with diabetes that the noble Lord, Lord Patel, described who ended up with the potentially unnecessary amputation of toes. Integrated care could have improved the clinical outcome in that case by avoiding a deterioration of the patient. Careful supervision in the community and the appropriate integration of different specialties and disciplines could have avoided that outcome. We know that integrated care has the opportunity to drive improved patient experience. We have heard about the potential for integrated care to improve patient safety. The example given by the noble Baroness, Lady Cumberlege, of the remarks made by Martin Marshall with regard to "lost in the system" puts patients at great risk, and the importance of integrated care and enhancing patient safety should not be neglected.
	We also know that integrated care can achieve the important objective of taking our system towards a value-based healthcare system where, in addition to improving all the good clinical outcomes and improvement in experience and safety, the healthcare system can also deliver better value and ensure that the vital resources available and devoted by Government to the provision of healthcare can be used most effectively. Therefore, I strongly support the amendments that speak to the need to emphasise in the Bill the importance of integration.
	The Bill has the important purpose of ensuring that a legal framework exists for driving forward future provision of the National Health Service, and also provides an important opportunity to set a vision and ensure that those ultimately responsible for implementation have an appropriate focus at the outset and can design the service moving forward in such a way that it achieves the objectives and meets the challenges that the noble Earl set at Second Reading. To ensure that there is a focus on integration is a very important objective. It will help achieve those important challenges. Failure to emphasise integration would run the serious risk of losing the opportunity to drive forward the improvements in healthcare and in the utilisation of resources that the health service desperately needs.

Baroness Barker: My Lords, the noble Baroness, Lady Pitkeathley, mentioned that she wrote a book 40 years ago. I wish I had written a book about the experiences of older people in various parts of the healthcare system. Many noble Lords talked about integration at different levels. My view is that integration just within acute hospitals will be ever more complex in future because they will be treating many people with dementia. The treatment of people with dementia in different parts of acute hospitals is a growing scandal. It poses a challenge to health professionals of all kinds, many of whom have never bothered to think about the issue of dementia. They will have to think about it for their own specialisms in future.
	I have taken part in this sort of debate many times and come to the conclusion that the debate rests on a single factor: information. It is the sharing and availability of information and data about outcomes. Everything else is secondary. The previous time we had a serious discussion about this was when we discussed the proposals of the noble Lord, Lord Darzi. Some of what he achieved, in particular in improving stroke care in London, rested on the willingness and ability of people just in different parts of the NHS-let us not be too ambitious-to share information. I ask the Minister what the department has learned since the passage of the legislation of the noble Lord, Lord Darzi, about the crucial issue of sharing information about patients and their treatments, and other data on outcomes. Until we address that issue, and until health professionals feel able to maintain client confidentiality while sharing information just with other professionals, everything else will be redundant: we will never crack any of this until we get that right. Therefore, I ask the Minister how the department's thinking was influenced in the preparation of the Bill by what the noble Lord, Lord Darzi, achieved.

Baroness Masham of Ilton: My Lords, integration has been said to be important and I agree. I agree also how important specialised nurses are to those with long-term conditions such as diabetes, stroke, epilepsy, Parkinson's, tuberculosis, spinal injuries, many neurological conditions, rheumatoid arthritis and many more conditions. Specialist nurses should not be cut. They are the vital link between primary and secondary care. Pain control should be included in integration. Nothing so far has been said about it. Last night, I was at a presentation about rheumatoid arthritis, and it was stressed that pain control is important.
	Integration means much more with long-term conditions. Occupational therapists are employed by local authorities to adapt houses. What is going to happen in the new regime to the wheelchair service? Who is going to look after that? What about housing for those with serious disabilities? What happens now? If there is no suitable housing, patients stay in hospital far too long. Professionals should all be working together.

Baroness Armstrong of Hill Top: I want to intervene briefly. I support much of what my noble friend Lord Warner said in his opening speech. There are some things on which we need to tread carefully. Integration is critical, but it can become a phrase that is used but is not backed up by good practice. We have to be sure that we introduce or develop integration in ways that improve the outcome for patients. I serve as a non-executive on an acute trust in the north-east of England, the County Durham and Darlington NHS Foundation Trust. It has just merged with, or taken over-I am never very sure-the community trust. The Government have been encouraging this throughout the country. There are mergers and a coming together of community services and acute services. In some places, the community services are joining the mental health trusts and so on and so forth. We have been very conscious throughout that process that in the private sector the majority of mergers do not succeed. Very often that has been shown to be a problem in the health service. That is not a good idea. When we are looking at integration, we have to be very aware of what outcome we want. We should not just say, "If we bring all this together, it's bound to save money and it's bound to be a better service". It will end up that way only if it is exceptionally well planned, if the outcomes are worked out and are absolutely clear to people, and if we do it not just because it is the fashion of the day, or because the Government are asking for it to happen, or because the words are used in the Bill.
	I entirely agree with my noble friend Lord Warner. This should not be used as a means of excluding or cutting out competition. One of the best examples of integrated care that I have seen was when I was Minister dealing with social exclusion and had the real privilege of going to Preston. I was able to give £1 million to the local mental health voluntary organisation. It was working with people with learning difficulties who were trying to make sense of individual budgets. It was inspirational to meet the individuals who had been part of that development, which had been co-ordinated by the voluntary organisation-I think it was Mencap. It offered and provided one person to work with the patient, the client or whatever label you want to put on them. That person's job was to help the client negotiate their way through all the different organisations from which they needed care and to work out more effectively what they needed.
	I spoke to one young woman who had been living at home with her father. He was very concerned because she was becoming housebound, obese and more mentally ill, and she also had learning difficulties. Technically, every agency was working with her but nothing was actually happening to change her experience of life and her ability to get out and contribute, as well as her ability to find the right way through the organisations. She talked to me at great length with incredible enthusiasm and took me round the places that she now had contact with. She was volunteering in a group for severely disabled children, where she was simply holding someone's hand, being there and being a friend throughout the process. She told me she had reduced the number of hours of care she needed because she did not have time for it because she was so busy. She was busy being active as a volunteer in a whole range of things because the care she needed was now properly integrated and she had an advocate to help her work through the myriad of different things that she wanted; for example, where she needed particular drugs or care because of some physical illnesses. I was able to see true integration, with incredible enthusiasm from the patient, but it needed to be negotiated by the voluntary organisation. They were then able to get a pattern of care-a pathway, as we now call it-that made sense to her, that reduced her dependence on carers and professional intervention, but which worked for her. She was simply one example.
	I also think that the integration of care for children is really not as good as it should be. I have seen some examples of where it works brilliantly and others where it simply does not work at all for some of our most disabled and disadvantaged children. Again, we can do it better. Integration is absolutely where it should be but it will have to be organised in different ways for different types and groups of patients. There will need to be people who can help negotiate the way through the pathway.
	My experience in the County Durham and Darlington NHS Foundation Trust is that you have to be absolutely clear about what your outcomes will be. However you organise the different pathways and different coming together in groups-we are in the middle of doing that at the moment-there needs to be clarity about what you are trying to do in enabling the individual who is the concern of the local authority, the acute trust and the community trust. Someone has to negotiate that pathway with them, and that will frequently be someone who is not embedded in any of those areas of responsibility, although it may be someone from there. There will have to be different ways of doing it.
	The Government are going to have a very difficult job in making absolutely sure that integration is working for the patients rather than simply saying, "Well, we are doing yet another reorganisation which we hope will save money". My experience is that if that is all people think of at the beginning, it does not work, it saves no money and it becomes increasingly frustrating for the person whose care it is supposed to improve.
	I went to see someone in a community hospital that I have a lot of experience of. It is a fabulous place that traditionally takes patients from a number of different areas. The local authority recommends people, the GPs recommend people, and of course the acute trust recommends people it wants to get out of acute care and into the community hospital. Trying to get that knowledge and understanding into the acute trust, now that it technically runs the hospital, is quite difficult. It rings up at the beginning of the day and asks how many beds the hospital has. The hospital might say four, and the trust rings again at the end of the day and says that it needs those four beds. The community hospital matron might say that the GPs have taken two of them and the local authority has taken another, so the beds are no longer there for the acute trust.
	We need to make sure that we get integration right and recognise that we have to get the best and not simply use integration as a term that will cover everything.

Lord Beecham: My Lords, the hour is late and I will not speak for long, but I want to address one issue in this very important debate from the perspective of local government, in which I have so far spent two-thirds of my life. The issue is social care services, which are referred to in so many of the amendments.
	This is partly a question of definition. What do we mean by social care? Do we mean the services provided by adults' services departments, or do we take a broader view, such as the position of children's services, which were split away from social services departments, having first been integrated after the Seebohm report in the early 1970s? I have had and continue to have misgivings about that separation, but I take it that, for the purposes of these amendments, we should look at children's services as well as adults' services in relation to social care.
	As the noble Baroness, Lady Masham, has pointed out, there is also a housing aspect, which needs to be taken into account. That, of course, is a function of all principal councils. It is not a function of county councils, which are basically responsible for adults' services and children's services. It is, however, a function of district councils, and their role in relation to this provision also needs to be looked at.
	There is also the issue of finance and budgets. The National Health Service benefited enormously from investment by the previous Government. There was very much greater investment in that than in social care, so there are questions about how the funding of integrated care between local government and health is to go forward. Perhaps when he replies the Minister will comment on the experience of community budgeting, which in some cases has been looked at, to see how that can be developed. If it has not been sufficiently piloted, perhaps he will indicate whether the Government will consider using that mechanism for community budgets to pilot further integration along those lines. The Government should also bear in the mind the impact of their proposals for the reform of welfare and the benefits system on the position of people requiring social care.
	The noble Baronesses, Lady Cumberlege and Lady Armstrong, mentioned personal budgets, which clearly have considerable potential in the promotion and use of integrated care and for avoiding the cost-shunting that sometimes occurs. There is clearly a requirement for the kind of support to which the noble Baroness, Lady Armstrong, referred in helping people to navigate their way through that system and to maximise the efficiencies that can be obtained from it.
	Therefore, while I certainly support the first of these amendments, I think we need to be clear about what we are looking to integrate beyond simply adults' services.
	In that context, finally, in relation to role of the health and well-being board, there is the responsibility of producing joint strategic needs assessments. It is not clear to me-perhaps we will debate this issue later-the extent to which those boards will be able to redirect the provision of services as opposed to providing an assessment and being consulted on the commissioning that clinical commissioning groups will carry out.

Baroness Wheeler: My Lords, the hour is indeed late and I have done my best to cut back on bits of my speech. On behalf of the opposition Front Bench, I commend these amendments for beginning the process of retipping the balance of the Bill from its current predominance of measures dealing with NHS structures, governance and competition. Today's amendments start to explore ways of addressing in the Bill the need for the NHS, public health and social and community care to work together to achieve improvements in quality of services in diagnosing and treating patients. Integration is a means for achieving this and is not an end in itself.
	It is worth reminding ourselves of the recent warning from Chris Ham, chief executive of the King's Fund, of the very real risk in the Bill of integrated care being,
	"a sideshow involving small-scale pilots, with competition the main game in town".
	He also said:
	"If the Government is serious in its endorsement on the Future Forum's advocacy of integrated care, it must demonstrate its commitment by putting the best civil service brains on the case and ensuring that the mandate given to the NHS Commissioning Board has the promotion of integrated care at its heart".
	We are certainly not at that stage yet, as the contributions in this debate have demonstrated.
	The Bill offers the opportunity for the promotion and enabling of integration to be embedded into the work of the Secretary of State, the NHS Commissioning Board, clinical commissioning groups, health and well-being boards and Monitor, and further amendments throughout the Bill will allow for debate and development of these areas. The Royal College of Physicians has referred to these bodies needing to have, under the Bill, an explicit duty of mutual co-operation and collaboration, and this should be the aim. The Secretary of State, the Commissioning Board and Monitor all need to ensure that national policy promotes, not just enables, the supporting context for integration.
	We support working towards a strategic definition of integration that encompasses the NHS, public health and social and community care. Nuffield, the King's Fund, National Voices and the Local Government Association are all undertaking comprehensive work on producing clearer definitions, so there is no shortage of expertise in this area. Our hope is that this work will help lead us to a more coherent approach and ensure that current provisions in the Bill can be strengthened. As we know, the Future Forum is currently consulting on what now turn out to be the non-legislative steps that can be undertaken. But whatever recommendations it comes up with need to be in the context of a Bill which provides the strategic context, framework and direction. The National Voices key principles of integration have much to commend them in taking this work forward.
	Amendment 18A has a particular focus on integrating public health with local authorities. We strongly support the proposed role for local authorities for public health and this amendment would help to address fears of some public health professionals that this might lead to public health becoming divorced from the NHS. Amendments 182 to 184 look to clinical commissioning groups having particular regard for outcomes which show "effectiveness and integration" and integrating "assessment and delivery" by those who provide health and social care services. CCGs need to demonstrate that their commissioning plans address the physical health, mental health and social care needs of their local population under the joint strategic needs assessment.
	In this regard, one of the major ways of promoting integration will, as many noble Lords pointed out at Second Reading and today, be by strengthening the powers of health and well-being boards. We strongly support giving health and well-being boards the power to sign off the commissioning plans of CCGs and will be supporting amendments to achieve this later in the Bill. If health and well-being boards own the health and well-being strategy, they must also own the plans to deliver it.
	Finally, at the beginning of the debate on how we use legislation to promote integration of services and care, as a carer myself perhaps I may endorse noble Lords who have underlined the importance of this issue to carers. Carers, particularly of people with long-term conditions, oversee care packages across the NHS, local authority social care, the independent agency and provider sector and the voluntary sector. Carers are often the principal players in organising the care package and the ones who fight to hold it together. Hours can be spent going over the same information for different parts of the system or ensuring that one part of the system is aware of decisions and developments, and any possible knock-on effects, taken in other parts of the system involved in the care pathway. Joined-up support is the key enabler for people with severe disabilities or long-term health conditions to remain at home and it is crucial that the Bill gets this important issue right.

Earl Howe: My Lords, all the amendments in this group have the entirely laudable aim of improving the integration of services across health and social care and improving access to services. I agreed strongly with many of the messages which the noble Lord, Lord Warner, delivered in his excellent speech, and with so many of the powerful contributions from other noble Lords. The only person with whom I felt seriously out of sympathy was the noble Lord, Lord Davies of Stamford. I would simply say to him that the Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors to improve patient outcomes through far more co-ordinated working.
	For example, the reformed system that this Bill will give form to-the provision of high-quality, efficient and fair services-represents the fundamental goals of the health and care service. This clause puts on to a statutory footing the three domains of quality identified by the noble Lord, Lord Darzi, in his next stage review: effectiveness, safety and experience. Every aspect of healthcare quality fits into the Darzi domains, and that is a tribute to the noble Lord's work in co-producing the quality framework with patients and the professions, and it is also why the domains still provide the framework for quality.
	In answer to my noble friend Lady Jolly, or at least to give her a partial answer, we seek to measure success in meeting these fundamental goals through the transparent accountability mechanisms of the outcomes frameworks for the NHS, public health and social care. Integration and access, though laudable objectives that I share with all those noble Lords who have spoken about them, are a means to this end. If integration and access help the NHS to meet the quality and fairness duties-and by fairness I mean reducing inequalities-then integration and access will need to be factored in to commissioners' plans. Commissioning guidance will set out how best to achieve this based on the accredited evidence of what works best that NICE is developing in its quality standards and other guidance.
	The point is often made that high-quality care must surely be integrated care. Integration is not an outcome, it is a possible feature of the process. Where it will improve outcomes and reduce inequalities, integration should most certainly happen, and this Bill provides for that. But we must not sacrifice outcomes for process. I thought the noble Baroness, Lady Armstrong, injected a welcome dose of reality on that theme borne out of her considerable experience, and although I did not fully agree with everything that the noble Baroness, Lady Wheeler, said, she also made some very sensible comments on that point. Indeed, the NHS Future Forum's Phase 1 report highlights well the practical rather than legislative challenge of bringing about more integrated services for patients. I shall quote from its summary report, which states that,
	"legislating or dictating for collaboration and integration can only take us so far. Formal structures are all too often presented as an excuse for fragmented care. The reality is that the provision of integrated services around the needs of patients occurs when the right values and behaviours are allowed to prevail and there is the will to do something different".

Lord Davies of Stamford: My Lords, I am most grateful to the noble Earl for giving way. Of course we all agree about the importance of the right values and behaviours. I know he did not like my questions, but perhaps he would answer at least two of them. First, what concrete, specific measure in this Bill, if any, addresses the perversities currently existing in the integration of social care and NHS care? Secondly, what about Northern Ireland? Why is the system that exists in Northern Ireland, where the provision of the two is entirely integrated, not suitable for England?

Earl Howe: My Lords, if the noble Lord will be patient, I will proceed and answer his questions at the end, as I normally do.
	It was in recognition of these practical challenges that the Government asked both the NHS Future Forum and the King's Fund, jointly with the Nuffield Trust, to provide further advice on the practicalities of achieving more integrated services around the needs of patients. We look forward to receiving their advice later this year. So we share entirely the intentions of noble Lords, and that is why Clauses 20 and 23 contain proposed new Sections 13M and 14Y to create duties for national and local commissioners to promote integration across health and social care-that is the first part of my answer to the noble Lord, Lord Davies.
	New Section 13M creates an NHS Commissioning Board duty to promote integration. Rather than simply requiring the board to encourage clinical commissioning groups to work closely with local authorities, as under this amended duty, the board is required to promote integration by taking specific action to secure that services are provided in an integrated way where it considers that that would be beneficial to the people receiving those services. The duty requires the board to exercise its functions with a view to securing that health services, health and social care services and health and other health-related services are provided in an integrated way where it considers that this would either improve the quality of health services and the outcomes they achieve, or reduce inequalities in access to and outcomes from health services. By other health-related services, I mean services such as housing, which may have an effect on the health of individuals but are not health services or social care services.
	This requirement would cover both integration between service types-for example, between health and social care-and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This would apply to all the board's functions not just when exercising its commissioning functions, including when it exercises public health functions under arrangements with Public Health England.
	The duty also requires the board to encourage clinical commissioning groups to enter into partnership arrangements with local authorities under Section 75 of the NHS Act 2006 where this would secure the provision of services in an integrated way, or that the provision of health services is integrated with the provision of health-related services or social care services. Proposed new Section 14Y creates a similar duty for local clinical commissioning groups.
	The changes to the regulatory framework give Monitor a role in Clause 59 in relation to improvement in quality and fairness as well as efficiency.
	The question then is: what actual risk exists of fragmentation at the national level? There is no such risk. Our outcomes frameworks span public health, the NHS and social care; the Secretary of State will aim to improve outcomes in all three components of the care system; NICE will provide quality standards across the whole patient pathway that will push for integrated care; and the care system, nationally as well as locally, will have to pay attention. The Secretary of State's duties and his actions are, in other words, an embodiment of integration.
	Our reforms are firmly focused on improving quality and outcomes for patients. We are not in the business of dictating the processes by which this improvement might be achieved, or trying to measure success in terms of whether a particular process has been put in place regardless of whether it actually delivers a good outcome for patients. I make no apology for that. We are of course committed to enabling and facilitating integration, but integration is neither a necessary nor a sufficient condition of a good outcome.
	Perhaps more importantly, our reforms aim to encourage measurement and reporting throughout the system that will tell us whether it is achieving what we have said it should achieve. Accountability should finally have arrived at all levels in the system. Improvement should result and will be understood through the outcomes frameworks in terms of the actual outcomes achieved and those that matter most to patients, service users, their families and carers and the wider public.
	The noble Lord, Lord Patel, asked me how competition and integration will work together. As the NHS Future Forum said in its report, co-operation and competition are not mutually exclusive. Both have vital roles to play in improving NHS services. For example, competition enables a patient requiring a hip replacement to choose to have their operation in the hospital that best suits their needs. Should that patient then require rehabilitation and support from local community services after their operation, co-operation is equally crucial in ensuring that this is provided in a co-ordinated and integrated way. However, there have been concerns about how competition and integration can work together, and in particular that competition would prevent integration. In response, we introduced safeguards to prevent this. First, Monitor's core duty is now clear: patients' interests always come first. Where an integrated service raises competition concerns, Monitor will focus on what benefits patients. Its role will be to ensure that the benefits to patients outweigh any negative effects of competition. Secondly, Monitor has new duties to support integration where it is in the best interests of patients, working with others to enable integrated care.
	I listened with growing bafflement to the noble Lord, Lord Davies of Stamford-I do not mean that in too derogatory a way. He used the words "extraordinary timing" about the Bill and said that we had missed a trick by not considering health and social care together. I cannot agree with his analysis. I remind the noble Lord of some of the history of social care reform. It is difficult and complex, and requires careful consideration, which may explain why the previous Government never got close to a workable plan. That is why we feel that the process that we put in place last year, with the commission headed by Andrew Dilnot, was the right one. That has not stopped us considering how the Bill can improve health and social care working together in the ways that I have set out.
	The noble Lord asked why the system in Northern Ireland is not applicable in England. The simple answer is that health services in different areas develop in different ways. Successive Governments have endorsed a commissioner/provider split as a key way to drive quality and efficiency. The Government fully subscribe to that principle and are promoting integration within that context.
	The noble Lord challenged me to cite one example of how the Bill improves the legal framework to support integration. I have mentioned one or two. We have drafted the Bill with consideration of how the structures it establishes can support integration more effectively than the current system-for example, how CCGs will be different from PCTs. At present, PCTs do not have any duties relating to integration other than the need to co-operate with other NHS bodies and local authorities. We felt that that was insufficient and those who have spoken tonight appear to agree. As such, CCGs have duties not only to co-operate but also to promote integration. That is again in new Section 14Y, which I mentioned earlier. They also have to be part of health and well-being boards, agreeing a joint strategy which their commissioning plans should be consistent with. I say this not to imply that integration as an issue is solved but that we have thought very carefully about the role that legislation can play in supporting integration. The Bill is drafted on that basis.
	My noble friend Lady Cumberlege highlighted the importance of personal health budgets in helping to improve integration of services for individual patients. I absolutely agree with what she said. In our response to the NHS Future Forum report, we committed-subject to evidence from the current pilots-to using the mandate to the board to make it a priority to extend personal health budgets, including integrated personal budgets, across health and social care.
	My noble friend Lady Barker raised the crucial issue about information sharing. I agree that appropriate sharing of patient information is absolutely vital to ensuring the high-quality provision of care. Our intention is to move to a system whereby the information centre holds confidential information securely and can join up data from a number of sources, for example-and crucially-linking interventions with outcomes. The information would be made available more generally in anonymised and de-identified forms, so it could be used for many purposes, including to enable more integrated provision of care and for public accountability. This is an area that is under development, but it is an area in which the information centre will play a key role.
	The noble Lord, Lord Beecham, asked about the community-based budgets. We want to ensure that GPs and councils have the flexibility to pool and align funds locally, where this will improve outcomes for local people. We think that health and well-being boards provide the ideal forum for local application of community budgets, and we intend to explore any barriers to pooling and aligning through early implementers for health and well-being boards.
	My noble friend Lady Jolly asked how we would measure the effectiveness of integration and how we would report on it. Both points were extremely important. The NHS outcomes framework sets out the areas in which the NHS must improve in order to fulfil the system-wide quality duty with the supporting suite of indicators. Integration per se, as I have indicated, is neither measurable nor an explicit outcome, but the results of integration will show through in measured improvements in outcomes. As for reporting, CCGs' annual reports will have to cover all the CCGs' functions and duties including their duty to promote integration.
	The noble Lord, Lord Patel, spoke about diabetic care and pointed out that it was all too often fragmented. As he will know, NICE published a quality standard in diabetes earlier this year, which addressed care along the patient pathway and included guidance on avoiding foot ulceration and other avoidable co-morbidities. Indeed, NICE quality standards are intended to describe integrated care.
	The noble Baroness, Lady Masham, asked what would happen to wheelchair services in the new system. CCGs will commission wheelchair services, taking on the function from PCTs. In doing so, they would want to work and co-operate with their local authority colleagues.
	The noble Lord, Lord Warner, asked me specifically whether I was up for further integration amendments. He spoke eloquently about the need for integration to be more than just a rhetorical flourish. I could not agree more; what we need to do is to focus on the changes that will make a real difference. For example, how do we ensure that professionals from health, social care, social services and others work effectively together when their functions overlap? It is precisely that sort of level of technical and essentially non-legislative detail that the Future Forum is looking at now-and I look forward to its report. So while I would not say that my mind was closed to amending the Bill further with regard to integration, I am very keen that our focus as a Government is trained on making a real difference, whether in the Bill or outside it.
	With that, I hope that I have covered the points and questions that have been raised and respectfully suggest that the amendment is withdrawn.

Lord Warner: My Lords, this has been a good debate. The hour is late but I want to make a couple of points in response to the noble Earl. There is probably a fundamental difference between him and me and, I suspect, other Members on this side of the Committee about whether integration and access are just bits of process and whether we should focus entirely on outcomes. I say gently to the noble Earl that the public care about some of those processes. That is why we had targets for access; they care about access and integration. The outcomes framework will not adequately measure either of those areas, which are of public concern. Indeed, they are important contributors to good outcomes. Therefore, we probably have a philosophical difference of view over how we approach those issues.
	I do not want to go over this ground tonight. However, we must look at the Bill to see whether it can give stronger signals to professionals and the culture in which they operate about the importance of integration, not just within healthcare but across the boundary between healthcare and social care. I hear what the noble Earl says but, looking at the Bill, I do not believe that the Bill goes far enough in changing that culture. I will certainly talk to some of these outside experts with a number of colleagues to see if we can come back with some amendments. I am happy to talk to the noble Earl about that with my colleagues before Report stage. I hope we can convince him that we can strengthen the Bill in this area. With that, I beg leave to withdraw the amendment.
	Amendment 12 withdrawn.
	House resumed.

House adjourned at 10.26 pm.